Systems and methods for recovery from motor control via stimulation to a substituted site to an affected area

ABSTRACT

A device and methods for treating a subject with dysphagia or other neurological disease, neurological disorder, neurological injury, neurological impairment or neurodegenerative disease that affects voluntary motor control of the hyoid, pharynx, larynx, or oropharyngeal area is disclosed. A device of the invention generally comprises a vibrotactile stimulator for applying at least one stimulus to the outside surface of a subject&#39;s neck; a connector for attaching the vibrotactile stimulator to an outside surface of the subject&#39;s neck, and a switch control communicatively connected to the vibrotactile stimulator to selectively engage a manual stimulation module and/or automatic stimulation module. Stimulation of an outside surface of the throat area of a subject by a device of the invention stimulates a swallowing reflex in the subject.

CROSS-REFERENCE TO RELATED APPLICATIONS AND INCORPORATION DATA

This application is a continuation of U.S. patent application Ser. No.12/211,633, filed Sep. 16, 2008, issuing on Mar. 5, 2013 as U.S. Pat.No. 8,388,561, which is hereby incorporated by reference in itsentirety. U.S. patent application Ser. No. 11/993,094, filed Dec. 19,2007, PCT Patent App. No. PCT/US2006/025535, filed Jun. 30, 2006, U.S.Prov. Patent App. Ser. No. 60/695,424, filed Jul. 1, 2005, U.S. Prov.Patent App. Ser. No. 60/787,215, filed Mar. 30, 2006, and PCT PatentApp. No. PCT/US2007/007993, filed Mar. 30, 2007, are all herebyincorporated by reference.

STATEMENT OF RIGHTS TO INVENTION MADE UNDER FEDERALLY SPONSORED RESEARCHAND DEVELOPMENT

The work performed during the development of this application utilizedsupport from the National Institutes of Health. The United Statesgovernment has certain rights in the invention.

TECHNICAL FIELD

The present disclosure relates generally to systems and methods fortreating and managing neurological disease comorbidities. Morespecifically, the present disclosure relates generally to systems andmethods for treating and managing diseases and disorders affecting themuscles of the neck and/or pharynx.

BACKGROUND

A wide range of neurological diseases and disorders exist that are notwell addressed by present medical technology. Among these, dysphagia (aswallowing disorder that affects the central nervous system therebyweakening neuromuscular control and effectively reducing the ability toproperly swallow) is a particularly life threatening disorder placingpersons at risk of aspiration pneumonia. Patients at risk of aspirationpneumonia have a 17% survival rate over three years (Pick et al., 1996).Estimates are that over 7 million persons in the U.S. have dysphagia asa result of neurological diseases or disorders such as stroke, traumaticbrain injury, brain tumors, Parkinson's disease, multiple sclerosis(Humbert, Lynch and Ludlow, in preparation 2008) and other neurologicaldiseases and over 300,000 persons develop a swallowing disorder as aresult of a neurological disease or disorder in the United States eachyear. Over 50% of patients with neurological diseases or disorders areat risk of aspiration pneumonia because of loss of central nervoussystem control of their swallowing resulting in either delayed orreduced elevation of the hyolaryngeal complex, which does not allow themto prevent food or liquid from entering the airway (Lundy et al., 1999).Normally the hyoid and larynx are raised by about 20 mm duringswallowing producing an inversion of the epiglottis and assisting withopening of the upper esophageal sphincter.

Frequently, patients having dysphagia require 24-hour attention toprevent aspiration and ensure that the passage of food and/or fluids,particularly saliva, into the respiratory system is minimized. It haspreviously been shown that glass rod pressure stimulation to the faucialpillars in the mouth can trigger swallowing (Pommerenke, 1927) whilechemical blocks of laryngeal sensation severely impair volitionalswallowing in normal adults (Jafari, Prince, Kim, & Paydarfar, 2003).Pharyngeal stimulation can initiate laryngeal closure and elevation forswallowing in animals (Jean, 1984), while laryngeal stimulation willtrigger a swallow (Nishino, Tagaito, & Isono, 1996). In humans, whensensory stimulation of the oropharynx is presented during a periodseparate from swallowing, it enhances cortical activity in theswallowing regions (Fraser et al., 2003; Hamdy et al., 2003; M. Power etal., 2004; Lowell et al., 2008), but does not benefit subsequentswallowing in dysphagic patients (M. L. Power et al., 2006). Theseapproaches to stimulation, however, generally involve the placement of adevice or probe into the oral cavity which interferes with eating foodand liquids and can alter oral sensory function in patients alreadyhaving oral sensory deficits.

Accordingly, there is a need for therapeutic methods and a device forenabling those who are afflicted with dysphagia or other conditions ordisorders that affect the ability to properly swallow withoutinterfering with oral function or altering oral sensory function.

SUMMARY

A device and methods for treating a subject with dysphagia or otherneurological disease, neurological disorder, neurological injury,neurological impairment or neurodegenerative disease that affectsvoluntary motor control of the hyoid, pharynx, larynx, oropharyngealarea, is disclosed. The device and methods of the invention can also beused to treat a subject with a speech disorder.

A device of the invention generally comprises a vibrotactile stimulatorfor applying at least one stimulus to the outside surface of a subject'sneck. The at least one stimulus comprises a vibrational stimulus, anauditory stimulus, a temperature stimulus, a visual stimulus, anolfactory stimulus, a gustatory stimulus, or a combination thereof. Thevibrotactile stimulator comprises at least a vibrational transducer; amanual stimulation module to manually engage the vibrational transducer;an automatic stimulation module to automatically engage the vibrationaltransducer; and a manual counter and/or an automatic counter fordetermining the number of times the manual stimulation module and/or theautomatic stimulation module is engaged.

In an embodiment, the vibrational transducer produces a wave having afrequency of about 50 Hz to about 70 Hz. In certain embodiments, thevibrational transducer produces a wave having a frequency of 59 Hz. Inan embodiment, the automatic stimulation module comprises an automatictimer. The automatic timer can include an automatic clock to initiatethe onset of the automatic stimulation module; an adjustable clock toinitiate the automatic stimulation module at an adjustable interval ofabout 0.5 s to about 30 minutes; and an adjustable timer that allows forsetting the duration of stimulation of about 100 ms to about 10 s.

A device of the invention also generally comprises a connector forattaching the vibrotactile stimulator to an outside surface of thesubject's neck. The connector can be adjusted by an adjustment mechanismfor positioning a contact section of the vibrotactile stimulatorsubstantially over the subject's larynx. A device of the invention alsogenerally comprises a switch control communicatively connected to thevibrotactile stimulator to selectively engage the manual stimulationmodule and the automatic stimulation module.

A device of the invention can also include one or more physiologicalsensors electrically coupled to the vibrotactile stimulator; aswallowing receptor comprising a piezoelectric stretch receptor; abattery, contained within the vibrotactile stimulator, acting as a powersupply for the device; and a control box for selecting one or more ofthe stimulus mode, stimulus type, stimulus rate, and stimulus amplitude.The physiological sensors can include movement sensors, temperaturesensors, skin color sensors, hematocrit sensors, oxygenation sensors,and blood pressure sensors. In one example embodiment, a swallowingreceptor comprises a piezoelectric accelerometric movement sensor.

A device of the invention can also include a digital clock generator forproducing an initial clock signal having a first frequency range; adigital decade counter for receiving the initial clock signal andproducing sequential pulses having a second frequency range; and a motorresponsive to the sequential pulses for producing vibrations on thesubject's larynx, having a third frequency range. In an embodiment, theinitial clock signal is adjustable and comprises a frequency. In anembodiment, the frequency of the clock signal comprises about one signalevery 3 minutes to about one signal every 30 minutes. In an embodiment,the second frequency range is about 1 Hz to about 10 Hz, or about 20 Hzto about 75 Hz, or about 30 Hz to about 60 Hz with durations of about 10ms to 500 ms. In an embodiment, the third frequency range is about 15 toabout 200 Hz or between about 20 and about 100 Hz. The motor can includea planetary gearbox. In an embodiment, the motor produces a vibrationalfrequency of about 50 Hz to about 70 Hz.

Methods for treating a subject with dysphagia or other neurologicaldisease, neurological disorder, neurological injury, neurologicalimpairment or neurodegenerative disease that affects voluntary motorcontrol of the hyoid, pharynx, larynx, oropharyngeal area, orhyolaryngeal complex disorder with a device of the invention is alsodisclosed. The methods of the invention can also be used to treat asubject with a speech disorder.

In one aspect, methods for inducing a swallowing reflex in a subject toprevent drooling and/or aspiration of the subject's own secretions aredisclosed. The secretions can be saliva and/or mucus. The methodsgenerally comprise applying a device of the invention to an outsidesurface of the subject's neck substantially over the subject's larynxand configuring an automatic timer to activate the vibrotactilestimulator to induce the swallowing reflex. In an embodiment, activationof the vibrotactile stimulator produces vibrations at a frequency ofabout 40 Hz to about 70 Hz and applies pressure of about 1 psi to about14 psi to the subject's neck during an onset period. In an embodiment,the onset period comprises about 10 ms to about 1.5 s, about 50 ms toabout 750 ms, or about 100 ms to about 500 ms. In an embodiment, anautomatic timer of the device of the invention is configured to activatethe vibrotactile stimulator at an interval of about once every 3 minutesto about once every 30 minutes.

In another aspect, methods for identifying a subject at risk ofaspiration from their own secretions are disclosed. The methodsgenerally comprise applying a device of the invention to an outsidesurface of the subject's neck substantially over the subject's larynx;downloading data from the vibrotactile stimulator after a period of useof the device by the subject; and analyzing to data to determine if thesubject is at risk of aspiration from their own secretions. The subjectactivates the device to induce volitional swallowing and the devicerecords the data to allow a health professional to determine if thesubject is at risk.

In yet another aspect, methods for monitoring patient compliance with atraining or therapy regime are disclosed. The methods generally compriseapplying a device of claim 1 to an outside surface of the patient's necksubstantially over the patient's larynx, wherein the patient activatesthe device to induce volitional swallowing; downloading data from thevibrotactile stimulator after a period of use of the device by thepatient; and analyzing to data to determine the patient's compliancewith the training or therapy regime.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is an example system incorporating a device for use in volitionalswallowing retraining.

FIG. 2 is an example diagram illustrating the neural circuitry involvedin the concurrent use of hand control and substitute sensory stimulationto enhance volitional swallowing.

FIG. 3 is a graph depicting conceptualization of events post braininjury.

FIG. 4 is a general block diagram of a vibrotactile stimulator accordingto principles of the present disclosure.

FIG. 5 is a more detailed block diagram of the vibrotactile stimulatorof FIG. 4.

FIG. 6 a is an example circuit diagram of the vibrotactile stimulator ofFIG. 5 including a manual and an automatic counter.

FIG. 6 b is an example circuit diagram of the vibrotactile stimulator ofFIG. 5 without a manual and an automatic counter.

FIG. 7 is an example automatic timer circuit block diagram.

FIG. 8 a is example circuit diagram of the automatic timer circuit asshown in FIG. 7.

FIG. 8 b is an alternative example circuit diagram of the automatictimer circuit as shown in FIG. 7.

FIG. 9 an alternative embodiment of a vibrotactile stimulator of thepresent disclosure.

FIG. 10 is an example circuit diagram of the vibrotactile stimulatorshown in FIG. 9.

FIG. 11 is a diagram depicting a clock based sequential vibrator controlas implemented with the vibrotactile stimulator of FIG. 9.

FIG. 12 is a diagram of the controller box for the vibrotactilestimulator as shown in FIG. 9.

FIG. 13 is a plot illustrating that vibratory stimulation to the skinover the throat at about 59 Hz produces the most frequent reports of anurge to swallow.

FIG. 14 is a graph showing individual patient pre-training baselineTotal Score without stimulation or button press training representingthe degree of risk of aspiration during swallowing and post-trainingTotal Score following button press training for coordinating swallowingwith intramuscular stimulation. An increased score represents a greaterrisk of aspiration during swallowing.

FIG. 15 is a graph showing individual patient pre-training baselineswallowing NIH safety score at baseline before button press training (anincreased score represents a greater risk of aspiration duringswallowing and post-training). Total Score following button presstraining for coordinating swallowing. FIG. 15 shows that button presstraining alone can improve swallowing safety as the Total Score reducedsignificantly.

FIG. 16 shows post training mean values for each participant during offand on stimulation conditions. Lowering of the hyoid position on the yaxis in the neck is shown with high levels of electrical stimulation onthe neck.

FIG. 17 depicts the traces of hyoid position during high electricalstimulation “on”, then stimulation turned “off” followed by stimulation“on” for each of the participants in the study. High levels ofelectrical stimulation on the throat area lowers the hyoid bone whenstimulation is “ON.” The hyoid is only able to return to a normalposition in the neck when stimulation is “OFF”. Because of this action,high motor levels of electrical stimulation interfere with the usualelevation of the hyoid bone which is required for swallowing.

FIG. 18 is a presentation of individual patient reductions in aspirationseen in comparison with swallowing without stimulation versus swallowingwith low levels of electrical stimulation at approximately 2 milliamps(mA) applied on the throat. This shows that sensory levels ofstimulation enhance swallowing safety.

FIG. 19 shows a line graph showing individual participants rating duringthe stimulated and non-stimulated swallows at motor levels ofstimulation on the NIH Swallowing Safety Scale. This graph is autoscaled to the range of the data in the condition. Therefore FIG. 19 ison a larger scale than FIG. 20. FIG. 19 shows that high motor levels ofelectrical stimulation (>8 mA) do not benefit swallowing in somepatients with swallowing disorders.

FIG. 20 shows a line graph showing individual participant ratings duringstimulated and non-stimulated swallows at motor levels of stimulation onthe NIH Penetration-Aspiration scale (Rosenbek et al., 1996). FIG. 20 isauto scaled to the range of the data in the condition. Therefore theFIG. 16 is on a larger scale than FIG. 20. FIG. 20 shows that high motorlevels (>8 mA) of stimulation do not benefit swallowing.

FIG. 21 is a plot of measured peak elevation of the larynx (LYPEAKCHNG)and the peak elevation of the hyoid bone during swallowing (HYPEAKCHNG)in normal volunteers from Humbert et al. (2006) with electrical surfaceneuromuscular stimulation demonstrating that motor levels of surfaceelectrical stimulation (8 mA or greater) reduce hyolaryngeal elevationduring swallowing in healthy adults.

DETAILED DESCRIPTION

The present disclosure relates generally to systems and methods fortreating and managing neurological disease co-morbidities and disordersaffecting the volitional control of muscles that are involved in raisingand lowering the hyoid/larynx and/or pharynx in the neck. Systems andmethods that produce deglutition stimulation and vocalizationstimulation and/or combinations of these are disclosed. In general,these types of stimulation may be volitionally coordinated andcontrolled electrically, mechanically, chemically or biologically. Forexample, in accordance with principles of the present disclosure, thecombined use of button press training with simultaneous vibratorypressure stimulation on the neck region of the larynx is employed tofacilitate voluntary control of swallowing. This method and systems ofthe disclosure are particularly useful for treating and managingsubjects having dysphagia.

Others have attempted providing stimulation to areas that are reduced insensory function to enhance swallowing in patients with dysphagia (Park,O'Neill, & Martin, 1997), and in normal volunteers (Theurer, Bihari,Barr, & Martin, 2005). For example, the device disclosed by Theurer etal. requires that a dental plate be constructed and placed over thelower teeth. This device interferes with mouth closing and thereforemakes it difficult for patients to control liquid in their mouth.Electrical stimulation of the faucial pillars in the mouth requires aprobe to be placed in the mouth, making it impossible for patients toswallow such that this method can only be used at a time separate fromasking the patient to swallow (Fraser et al., 2003; Hamdy et al., 2003;M. Power et al., 2004). Therefore, placement of devices into the oralcavity is not optimal as such devices will interfere with eating foodand liquids and alter the oral sensory function in patients (Theurer,Bihari, Barr, & Martin, 2005) who already have oropharyngeal sensorydeficits (Hagg & Larsson, 2004; Aviv, Sacco, Mohr et al., 1997; Setzenet al., 2003).

One important aspect of the present disclosure is that the device of theinvention is applied to an exterior surface of the throat area and notinside the mouth or the pharynx. A device placed inside the mouth or theoropharynx will interfere with eating. For example, the device disclosedby Park et al., (Park, O'Neill, & Martin, 1997) covers the mucosa inpart of the mouth or the roof of the mouth thereby interfering withnormal sensation for controlling the movement of the food or liquid inthe mouth using sensory feedback between the tongue and the roof of themouth.

Many patients with dysphagia already have oral sensory deficits(Logemann, 1993; Logemann et al., 1995). Providing stimulation toregions that are already impaired in sensation can be expected toprovide less sensory facilitation of volitional and reflexive swallowingthan sensory stimulation to unaffected areas. Therefore, the presentdisclosure is aimed at providing simultaneous sensory facilitation toareas unaffected by sensory deficits such as the skin overlying thethroat area and the vibratory sensors in the musculature and cartilagesin the throat area and the thyroid cartilage in particular. Vibratorystimulation of the thyroid cartilage and the stemothyroid muscle hasalready been shown to have powerful effects on voice (Loucks, Poletto,Saxon, & Ludlow, 2005). The methods and systems of the presentdisclosure differ from other previous approaches in that the patientinitiates the stimulation themselves immediately prior to swallowing andsuch stimulation is to an area that will not interfere with oral andpharyngeal movement and sensation during swallowing.

A. Stimulator Systems and Devices

Referring now to FIG. 1, an example system 100 incorporating a device inaccordance with the principles of the present disclosure is shown. Morespecifically, FIG. 1 depicts a device for treating dysphagia or a speechdisorder. For example, in general, a band 101 may be wrapped around theneck for dysphagia treatment. The band 101 may include a vibrator 102such that the vibrator 102 may be positioned over the larynx to providesensory stimulation. In certain embodiments, a designated contactsection 120 of the vibrator 102 is positioned to be in contact with theoutside of a subject's throat over the larynx. Additionally, the band101 can include an adjustment mechanism 125 for tailorable positioningof the contact section 120 over the subject's larynx. Upon activation ofan actuator 103, such as a button, switch or other equivalent actuatorcommunicatively connected to vibrator 102, on a utensil 104, such as aspoon, fork, or knife, held by the subject 105, the vibrator 102 isengaged and transmits vibrational energy to the throat and the larynx.Actuator 103 can be covered when not in use. In an embodiment, actuator103 may be a button in a small cover that is reversibly slid over thetop of a spoon handle or spoon handle shaped mount. Alternatively, theactuator 103 can be independent of the utensil. Thus, in one embodiment,actuator 103 is a remote switch that may or may not be physicallyconnected to the stimulating device.

In certain embodiments, a device to control one or more vibratoroperating can be provided. For example, a control box (not shown) havingappropriate switches, knobs, or dials can be provided to set a stimulustype, a stimulus rate (set or increasing) and/or a stimulus amplitude(set or increasing). Additionally, the control box can include featuresto determine stimulus duration. For example, the control box can beconfigured to allow for stimulation for a specific duration of time uponactivation of actuator 103 or as long as actuator 103 is depressed. Inone example embodiment the duration of stimulation is about 6 seconds toabout 25 seconds.

Referring still to FIG. 1, instructions can be provided to the subject105 for practice of initiating the sensory stimulation immediately priorto the subject's 105 own initiation of a motor act such as swallowing.The initiation may be coordinated by viewing on a display screen 106 amovement feedback signal 107. The movement feedback signal 107 can beprovided, for example, by a piezoelectric or pressure sensor 108 alsocontained in the neck wrap 101, which can be displayed on a displayscreen 106 when the motor movement begins. In one example embodiment, apiezoelectric accelerometric movement sensor is contained in the neckwrap 101. The signal 109 from the button 103, initiating sensorystimulation, can be presented on the same display screen 106 for thesubject 105 and a trainer to observe when the actuator 103 was activatedfor sensory stimulation in relation to the onset of the motor act orswallow. In this manner, the subject can learn to optimize the timing ofthe sensory switch to occur about 600 ms to about 200 ms prior to theonset of their motor act of swallowing. It will be appreciated thatactuation of the vibrator 102 via the actuator 103 may be accomplishedvia a hardwired connection or wireless telemetry. Similarly,communication between the movement sensor and the (display may behardwired or by wireless telemetry to relieve the subject 105 from thehardwired devices.

Without wishing to be bound by any one theory for this embodiment, it isbelieved that such motor training produces concurrent brain activationdue to sensory input that induces a central pattern generator in thepatient's brain stem that produces the related effect of swallowing. Itwill be appreciated to those skilled in the art that this principle isapplicable to many other neurological impairments, their associatedmotor act habituations and related sensory stimulations. Accordingly,the scope of the methods and systems of the present disclosure will beapplicable to that a large variety of patients having various diseasesand disorders.

Referring now to FIG. 2, an illustration 200 of the neural circuitryinvolved in the concurrent use of hand control and substitute sensorystimulation to enhance volitional swallowing is shown. Morespecifically, FIG. 2 illustrates the neural circuitry in using handcontrol 203 to trigger volitional swallowing 204 along with simultaneoussensory stimulation 201 which goes to the cortex 202. This isimplemented after button press training described above with respect toFIG. 1. Elicitation of the swallowing reflex and safety in swallowing isdependent upon sensory feedback 201 to the brain from sensorymechanoreceptors in the upper airway. If sensory input is withdrawn,persons feel that they can no longer swallow and are at significantincrease of aspiration during swallowing (Jafari et al., 2003). Theneural circuitry enhances cortical motor control 202 of swallowingcoincident with substitution of sensory input 203 from stimulation ofthe throat area to trigger brain stem circuitry to trigger reflexiveswallowing 204 simultaneous with volitional swallowing.

Referring now to FIG. 4, a general block diagram of a vibrotactilestimulator 400 is shown according to principles of the presentdisclosure. The vibrotactile stimulator 400 can be used in examplesystem 100. In certain embodiments, the vibrotactile stimulator 400 ispressed against the outside surface of subject's throat to stimulate thelarynx such that with coordination, the vibrotactile stimulator 400 canbe used to enhance volitional control of swallowing.

As described previously with reference to FIG. 1, the vibrotactilestimulator 400 may be secured or connected to a connector or a band thatcan be subsequently wrapped around the subject's neck. In this manner, adesignated contact section of the vibrotactile stimulator 400 can bepositioned on the subject's neck to stimulate the throat and larynx.Additionally, the connector can include an adjustment mechanism for afine adjustment of the contact section over the subject's larynx. Incertain embodiment, the adjustment mechanism shifts the position of thevibrotactile stimulator 400 within a circle having an area of about 0.01to about 10 cm²; about 0.25 to about 5 cm², or about 0.5 to about 2.5cm².

In general, the vibrotactile stimulator 400 includes a manualstimulation module 410 operatively configured to allow a user tomanually operate the vibrotactile stimulator 400 by pressing, orotherwise activating, an external actuator that communicativelyconnected to the vibrotactile stimulator 400. In general, the actuatorcan engage a vibrational transducer to transmit energy to a subject'slarynx. In one embodiment, the actuator is a pushbutton ON switch thatwhen pressed, or activated, energizes a vibrator motor 405 that vibratesat a desired frequency a periodic pressure wave that can transmitvibrational energy to the subject's larynx. In one embodiment, when theON switch is released the vibration produced by the vibrator motor 405is terminated. There is no delay between pressing the ON switch and thevibration to the throat area. In use, the manual stimulation module 410may be engaged during activities such as eating, drinking, andswallowing to prevent aspiration with patients having dysphagia.

Additionally, in the example embodiment, the vibrotactile stimulator 400includes an automatic stimulation module 415 operatively configured toautomatically energize the vibrator motor 405. In certain embodiments,the automatic stimulation module 415 enables the subject or caregiver toprogrammably define vibrator motor 405 operating parameters such asduration, vibrational frequency, and amplitude. For example, theautomatic stimulation module 415 can function to periodically energizethe vibrator motor 405 to induce swallowing throughout the course of aday, thereby reducing saliva aspiration (and in general for salivacontrol) for subjects afflicted with dysphagia, for subjects withneurological disorders who have uncontrolled drooling, and for subjectswith cerebral palsy who have uncontrolled drooling. In a preferredembodiment, the automatic stimulation module 415 includes an automatictimer circuit to facilitate the periodical energizing of the vibrationalmotor 405, as described in further detail below. In one aspect, theautomatic timer provides for continuous practice throughout the day,which is required for rehabilitation of speech and/or swallowingdisorders (Ludlow et al., 2008; Robbins et al., 2008). Automaticstimulation occurring at regular intervals of one every 3 minutes to oneevery 30 minutes will induce regular swallowing to eliminate drooling.

It will be appreciated to those skilled in the art that components ofthe vibrotactile stimulator 400 as described in the present disclosuremay be implemented via hardware and/or software techniques. For example,the vibrotactile stimulator 400 may include a printed circuit board(PCB). The PCB may comprise a plurality of discrete electricalcomponents such as transistors, capacitors, inductors, resistors andfunctional integrated circuitry such as a processor, a memory element,such as read-only memory (ROM) and/or random access memory (RAM), afield programmable logic array (FPGA) 1320, and input/output circuitry.

Referring now to FIG. 5, an example vibrotactile stimulator blockdiagram is shown as a possible implementation of the vibrotactilestimulator of FIG. 4. In general, upon engagement of a power switch 500,a battery 505 supplies power to a three terminal voltage regulator 510.In the embodiment as shown, the voltage regulator 510 is used as anadjustable current source to control vibrator motor 515 vibrationalfrequency. In practice, this may be accomplished by utilizing anexternal adjustable potentiometer 520.

Further, a switch control 525, such as a pushbutton, switch or otherequivalent actuator is provided to enable the user to selectively engagethe manual stimulation module 410 or automatic stimulation module 415.In certain embodiments the switch control 525 is communicativelyconnected to an external actuator such as a control box or a spoon. Inthe example embodiment, the switch control 525 is manipulated toelectrically load a switch interface 530 such that a count selectmechanism 535 is actuated. In this manner, a manual counter 540 isenabled when the user operates the vibrotactile stimulator 400 in themanual mode, and an automatic counter 545 is engaged when automaticstimulation is employed, as described further below. In a preferredembodiment, the automatic stimulation module 415 may be implemented withan automatic timer circuit such that the switch control 525 can becontrolled by the automatic timer circuit to actuate the count selectmechanism 535, thereby engaging the automatic counter 545 and energizingthe vibrator motor 405.

In the example embodiment the counters 540, 545 are internally mountedto the vibrotactile stimulator 400. The manual counter 540 records thetotal number of times a subject engages the manual stimulation module410. In a similar manner, the automatic counter records the number oftimes the automatic stimulation module 415 is engaged. Subsequently, thecounters 540, 545 may be interrogated, or equivalently read, and resetmanually after the total number of counts are recorded. In alternativeembodiments, a wireless data interrogation using one of manytechnologies, such as Blue Tooth, may be performed to transfer theinformation to an external application. The quantitative informationprovided by the counters 540, 545 may provide, for example, aninvestigator or caregiver quantitative information regarding patientcompliance and information regarding the effectiveness of thevibrotactile stimulator 400. As patient compliance is generally low,around 50% (Portone et al., 2008), it is important to the rehabilitationprocess to identify poor compliance particularly in the management ofdysphagia, a life threatening disorder. Identification of poorcompliance allows the therapist to intervene to assure proper use of thedevice by the patient and their caregivers.

In certain embodiments, the manual counter 540 and the automatic counter545 can be provided with their own internal power supplies so thatcumulative counts are not lost when the power switch 500 is disengaged.Additionally, the vibrotactile stimulator 400 may include a low batteryindicator 550 such that if the battery 505 voltage drops below aspecified voltage level an indicator specifying that event is generated.In the example embodiment an LED “Low Battery” indicator 555 comes on.

Referring now to FIG. 6 a, a circuit diagram 600 is shown illustratingone embodiment of a vibrotactile stimulator block diagram of FIG. 5. Itwill be appreciated to those skilled in the art that example circuitdiagram 600 is only an example circuit architecture and that thevibrotactile stimulator 400 may be implemented via any suitablearchitecture. In the example embodiment both passive and discreteelectrical components are chosen such that component attributes andtolerances fit a known specification. An alternative example circuitdiagram 605 of the vibrotactile stimulator block diagram of FIG. 5 isshown in FIG. 6 b.

Referring now to FIG. 7, a block diagram of an automatic timer circuit700 shown. In general, the automatic timer module is communicativelyconnected to the vibrotactile stimulator 400 as shown in FIG. 4. Aspreviously mentioned, the automatic timer circuit 700 may actuate thecount select mechanism 535, thereby engaging the automatic counter 545and energizing the vibrator motor 405 for a predetermined period oftime. In the example embodiment the automatic timer circuit 700comprises of a digital oscillator 705 having an adjustable oscillatingfrequency of about 2.2 Hz to about 28 Hz. The output signal of thedigital oscillator 705 is routed to a programmable timer 710 set todivide the periodic digital input signal by 4096. The input clockfrequency from the digital oscillator 705 to the programmable timer 710will determine when an output pulse is generated. In the exampleembodiment, the output pulse period may be generated in a range fromabout 3 to about 30 minutes. Subsequently, the programmable timer 710output pulse triggers an adjustable monostable multivibrator 715. Anoutput pulse width of the adjustable monostable multivibrator 715 setsthe “On” time for the vibrator motor 515 (as shown in FIG. 5) byenergizing a relay through a transistor switch. In the exampleembodiment, the transistor switch and relay control is integral to relaymodule 720. An LED 725 indicates that the relay has been activated,which is used to energize the vibrator motor 515 in the automatic mode.In an example embodiment, the selected time period may be about 5 toabout 15 seconds.

In general, the automatic timer circuit 700 is powered by a battery 730or other equivalent power source and a power switch 735. Additionallythe automatic timer circuit 700 may also include a low battery indicator740 such that if the battery 730 voltage drops below a specified voltagelevel an indicator specifying that event is generated. In the exampleembodiment an LED “Low Battery” indicator 745 comes on. It will beappreciated that the battery 730, the power switch 735, the low batteryindicator 740 and the LED 745 may be used to power the vibrotactilestimulator 400 as shown in FIG. 5.

Referring now to FIG. 8, a circuit diagram 800 is shown illustrating aone embodiment of the automatic timer circuit as shown in FIG. 7. Itwill be appreciated to those skilled in the art that example circuitdiagram 800 is only an example circuit architecture and that theautomatic timer circuit 700 may be implemented via any suitableelectrical architecture. Additionally, in the example embodiment bothpassive and discrete electrical components are chosen such thatcomponent attributes and tolerances fit a known specification. Analternative example circuit diagram 805 of the automatic timer circuitas shown in FIG. 7 is shown in FIG. 8 b. In certain embodiments, themanual counter 540, the automatic counter 545, and the automatic timercircuit 700 can be incorporated into a single functional counter andtimer module that is mounted internally and communicatively connected tothe vibrotactile stimulator 400.

Referring now to FIG. 9, an alternative embodiment of a vibrotactilestimulator 900 is shown. In general, the vibrotactile stimulator 900 isa battery-powered device that sequentially activates one or more smallDC vibrator motors as described herein. An adjustable digital clock canset the timing for separate events. The clock frequency can be adjustedbetween about 1 and about 10 Hz. This clock, in conjunction with adigital decade counter, generates sequential pulses that control theindividual vibrators “On” and “Off” duration. At the end of the pulsecycle, a short reset pulse is generated to reset the decade counter andbegin the next cycle of pulses.

A subject can control the vibrotactile stimulator 900 by pressing anexternal pushbutton “ON” switch. The switch will also activate an LEDindicator light and will generate a digital pulse that can be used forcoordinating various recording devices. When the button is released, thevibration pulses will stop. Preferably, there is no perceived delaybetween pressing the “On” switch and the first vibration to the throat.

Referring now to FIG. 10, a diagram of an example circuit 1000 of thevibrotactile stimulator 900 as shown in FIG. 9 is depicted.Additionally, FIG. 11 is a diagram 1100 depicting a clock basedsequential vibrator control as implemented with the vibrotactilestimulator 900 of FIG. 9. Further still, FIG. 12 depicts a diagram ofthe controller box 1200 for the vibrotactile stimulator 900 as shown inFIG. 9. The controller box 1200 may set one or more vibrotactilestimulator 900 operating parameters. For example, an operating parametermay include a stimulus type, a stimulus rate (set or increasing) anamplitude (set or increasing), or a combination thereof. Additionally,the control box may be configured to allow for stimulation for aspecific duration upon activation of the button or as long as the buttonis depressed. In an embodiment, the duration of stimulation is about 2seconds to about 6 seconds.

Referring now to the vibrator motor as utilized in the vibrotactilestimulator 900 as shown in FIG. 9 and in the vibrotactile stimulator 400as shown in FIG. 4. In operation, a vibrator motor vibrating frequencyof about 30 Hz to about 60 Hz is particularly effective in eliciting theswallowing reflex. The vibrator motor may be a low voltage DC motor witha planetary gearbox utilized to generate the effective frequency.

In operation the gearbox reduces the output rotation per minute (RPM) tothe desired range and increase the available torque. An eccentricallyloaded mass is attached to the output shaft to generate the vibration.The mass weight can be changed to increase or decrease the vibrationamplitude. In an embodiment, a lightweight, sealed aluminum tubeencapsulates the motor assembly. Further, in certain embodiments thevibrator motor may utilize a sleeve shaft for the output shaft. Inalternative embodiments the vibrator motor may utilize a ball bearingshaft for the output shaft.

In use, one or more vibrator motors can be placed on the front of theneck over the region of the thyroid cartilage. The one or more vibratormotors may be held in place by a rigid/semi-rigid holder or one or morestraps. The vibrators may be arranged on the inside of the holder tosuit the neck dimensions of the individual patient/user. An elasticstrap may be attached to the outside of the holder and is wrapped toattach in the back of the patient/user's neck to hold the holder inplace. A small, battery powered portable box connects to the button thatis pressed to drive the vibrators. In preferred embodiments, the deviceis supplied to the patient/user who is trained in its use by aspeech-pathologist or other professional with knowledge of swallowing,speech or voice disorders.

The stimulation device of the invention can be covered by a disposablecover, such as a plastic or a cloth cover. Stimulators may be containedwithin a stretchable device such as a wrap with Velcro and is adjustablefor individual patient bodies. Vibrator and electrical stimulators arepreferably positioned close to the skin. In another embodiment, thestimulation device of the invention includes one or more sensors ofphysiology, such as temperature, skin color, hematocrit, oxygenation,blood pressure and the like. In an embodiment the device reports resultsby a display and or by electromagnetic transmission and monitors and/orrecords swallowing events. For example, a device of the presentinvention can monitor the presence (and optionally depth) of aswallowing event via a piezoelectric stretch receptor or other sensor onor in the band around the neck, and/or at the surface over the larynx.(See Holzer and Ludlow, 1996; Burnett et al, 2005).

B. Methods and Uses

The systems and devices of the invention can be used to treat a numberof conditions and disorders including, but not limited to, stroke,cerebral hemorrhage, traumatic brain injury, dysphagia, post surgery tobrain, Parkinson's disease, multiple sclerosis, birth defects, ALS,cerebral palsy, CNS injury, supranuclear palsy, and any otherneurological disease, neurological disorder, neurological injury,neurological impairment or neurodegenerative disease that affectsvoluntary motor control of the hyoid, pharynx, larynx, oropharyngealarea, or hyolaryngeal complex. Neurological impairments that arecontemplated include reflex actions that involve interactions betweenafferent and efferent paths, at the spinal cord or in the brain stem, aswell as higher order interactions in the primary motor cortex of thehemispheres. The systems and methods of the present disclosure apply topatients who have lost or partially lost the ability to voluntarilycontrol motor functions but also to patients who were born with birthdefects that have prevented them from having voluntary motor control,such as cerebral palsy. The systems and methods of the presentdisclosure are also applicable to treating various speech motor controldisorders such as stuttering and laryngeal dystonia.

The term “motor control” as used herein refers to the ability to controlmuscle activity at will. For instance, in one embodiment, the inventionis applicable to the ability to swallow at will. Thus, patients withdysphagia, which is the complete or partial loss of the ability toswallow, can be treated with the methods of the present invention. In anembodiment, the disease or disorder reduces or delays motor control ofswallowing and/or results in delayed or reduced elevation of thehyolaryngeal complex, which does not allow the patient to prevent foodor liquid from entering the airway.

The methods of the invention generally comprise stimulating a substitutesite for the area with a system or device according to the invention,thereby triggering the motor control of the affected area. The term“recovering” as used herein includes within its meaning obtaining theability to volitionally control motor functions. “Volitionally” as usedherein means at the will of the patient. A “substitute site” as usedherein means an area of the body that is capable of eliciting a desiredreflex but is not a sensory region that is able to elicit reflex inimpaired patients.

Subjects are often not responsive to stimulation in the oral andpharyngeal cavities but remain sensate to vibratory stimulation to theareas of the human head which include anatomical structures (e.g.,muscles, nerves or connective tissue) that work in concert to affectdeglutition. By providing sensory stimulation to sensate areas on thethroat, substitute stimulation can be used to enhance the volitionalelicitation of swallowing. For example, patients with dysphagiafollowing neurological disease usually have sensory loss in theoropharyngeal area (Aviv et al., 1996; Aviv, Sacco, Mohr et al., 1997;Aviv, Sacco, Thomson et al., 1997) which is normally required to besensate in order to elicit safe swallowing without aspiration in normalvolunteers (Jafari, Prince, Kim, & Paydarfar, 2003). The presentinvention uses sensory triggering in “substitute sites” to enhance theelicitation of reflex and volitional swallowing, such as stimulation ofafferents from the laryngeal area contained in the superior laryngealarea (Jean, 1984), (Dubner, Sessle, & Storey, 1978), (Dick, Oku,Romaniuk, & Cherniack, 1993; Ootani, Umezaki, Shin, & Murata, 1995).

Basic studies suggest that the second order neurons excited by afferentsin the superior laryngeal nerve are selectively excitable at particularfrequencies (Mifflin, 1997) and that stimulation around 30 Hz may bepreferred for exciting the swallowing system in the brainstem (Dubner,Sessle, & Storey, 1978). Patients are often not responsive tostimulation in the oral and pharyngeal cavities but remain sensate tovibratory stimulation to the throat area including the skin andlaryngeal cartilages underlying the skin. Thus, the throat is asubstitute site and by providing sensory stimulation to the throat,enabling swallowing “at will” or volitional swallowing may be elicited.

The site for stimulation can be adjusted depending upon the desiredmotor control. One of skill in the art, such as a treating physician orother allied health professional with experience with the diseasecausing the motor impairment will readily understand where to locate thestimulation. In an embodiment, the affected area is the area of the bodyresponsible for swallowing, speech, or voice. In an embodiment, theaffected area is the oropharyngeal area. In an embodiment, thesubstitute site is the area of the throat over the larynx. In anembodiment, the recovered motor control is volitional swallowing.

By providing a vibratory stimulus to the patient's neck area,mechanoreceptors in the skin will be activated providing feedback to thebrain stem and brain to assist with triggering voluntary initiation ofswallowing, speech or voice. At greater vibration amplitudes, mechanicalstimulation induces movement of the thyroid cartilage and of theextrinsic and intrinsic laryngeal muscles in the region including: theplatysma, the stemohyoid, the sternothyroid, the thyrohyoid,cricothyroid and the thyroarytenoid muscles. Some of these musclescontain muscle spindles. The muscle spindle afferents can providesensory feedback to the central nervous system to assist with triggeringvoluntary initiation of the muscles for swallowing, speech and voiceinitiation.

In one embodiment, the stimulation is asserted immediately before avolitional attempt to move or carry out the physiological impairedfunction, such as swallowing or speaking. In an embodiment, thestimulation comprises an onset period in which the stimulation isasserted about 1 second to about 10 seconds before, about 0.1 second toabout 1 second before, about 0.2 second to about 0.5 second before, orabout 0.2 second to about 0.4 second before the volitional attempt. Thestimulation may also be asserted at the same time as the volitionalattempt. Preferably the stimulation of the affected body part is madevia a system or device according to the present disclosure before thevolitional attempt.

The sensory modality for stimulation includes but is not limited tovibratory stimulation, pressure stimulation, auditory stimulation,temperature stimulation, visual stimulation, electrical stimulation,olfactory stimulation, taste stimulation, and combinations thereof. Thestimulation may be controlled electrically, mechanically, chemically,biologically or by any other method known to the skilled artisan. In anembodiment, the stimulation is vibratory, tactile, pressure, or acombination thereof. In an embodiment, the stimulation is vibro-tactile.In an embodiment, vibration stimulation is combined with anotherstimulation, such as electrical skin surface stimulation (same timing ordifferent).

Vibratory stimulation desirably is applied at a frequency of about 1 toabout 100 Hz, about 5 to about 70 Hz, about 30 to 60 Hz, about 50 toabout 60 Hz, about 55 to about 60 Hz, or about 58 to about 60 Hz. In anembodiment, the pressure and/or electrical stimulation desirably isapplied at a frequency of about 50, about 51, about 52, about 53, about54, about 55, about 56, about 57, about 58, about 59, or about 60 Hz.The amplitude of vibration preferably may be, for example, about 1micron to about 2 mm. Amplitudes of about 100 micron to about 1 mm areuseful. In an embodiment, the vibrator produces a sequential wave ofpressure across bars (such as 1 to 5 oblong bars) at about 0.5 to about30 times per second, and more preferably about 2 to about 25 times, morepreferably about 5 to about 10 times per second. Desirably the pressuresare about 1 psi to about 14 psi with rise times of about 2 ms to about500 ms and more desirably rise times of about 4 to about 150 ms.

Electrical stimulation, if used, should be applied at a rate of 30 Hz atlow levels of less than about 2 mA over a small area of 1 cm² or 25 mAover a large area (about 10 cm²) or greater, or less if the area issmaller (less than about 10 cm²), such as about 0.01 to about 10 mA,about 0.1 to about 7 mA, about 0.5 to about 5 mA, or about 1-3 mA toassure only sensory stimulation is occurring and not resulting in musclecontraction. Levels that do not exceed about 10 mA, about 7 mA, about 5mA, about 4 mA, about 3 mA, and more desirably about 2 mA, areparticularly useful. In an embodiment, the electrical stimulationcomprises biphasic pulses (about 50 to about 300 microsecond pulses forexample) of about 1 to about 5 mA of current at about 15 to about 60 Hz.When electrical stimulation is utilized care must be taken to assurethat muscle contraction is not occurring as stimulation of muscles inthe throat area pull the hyoid downward and interfere with swallowing(Humbert et al., 2006; Ludlow et al., 2007).

In a preferred embodiment applicable to all stimulation types (pressure,vibration, electrical, etc) the amplitude of the stimulation (measuredas energy output or more directly as electrical current or vibrationdisplacement etc) and/or the rate of the stimulation pulse increasesduring the swallowing activity. In another embodiment the duration ofstimulation is set to the average measured, or expected duration of thepatient's swallow. In another embodiment, the stimulation lasts as longas the swallow is perceived to occur, or as long as a switch isactivated. However, to prevent central adaptation to the stimulation,the stimulation will only be turned on by the patient when swallowingand will remain off when the patient is not swallowing.

As disclosed herein, the patient that can activate a system or device ofthe invention stimulates their throat over the larynx thereby elicitingreflex swallowing. In an embodiment, the stimulation is vibratory,tactile, pressure, or a combination thereof. In an embodiment, thestimulation is vibrotactile. In an embodiment, the patient controls thestimulation via an actuator communicatively connected to the stimulator.The vibrotactile stimulate of the system and methods of the presentinvention provides substitute sensation to assist with elicitingswallowing while training the patient to volitionally control swallowingto substitute for their loss of reflexive swallowing. A system accordingto the present invention, can train the patient to press a button,switch or other equivalent actuator communicatively connected to thestimulator immediately before wanting to swallow thereby providing analternate sensory input via vibrotactile stimulation (or other similarsensory modalities) to the throat area to enhance volitional control ofswallowing of saliva.

The swallowing retraining systems and methods of the present disclosureprovides patients and their caregivers the opportunity to practicevolitional swallowing early in the post extubation period. FIG. 2illustrates the neural circuitry in using hand control 203 to triggervolitional swallowing 204 along with simultaneous sensory stimulation201 which goes to the cortex 202. This is implemented after button presstraining described above with respect to FIG. 1. Elicitation of theswallowing reflex and safety in swallowing is dependent upon sensoryfeedback 201 to the brain from sensory mechanoreceptors in the upperairway. If sensory input is withdrawn, persons feel that they can nolonger swallow and are at significant increase of aspiration duringswallowing (Jafari et al., 2003). The neural circuitry enhances corticalmotor control 202 of swallowing coincident with substitution of sensoryinput 203 from stimulation of the throat area to trigger brain stemcircuitry to trigger reflexive swallowing 204 simultaneous withvolitional swallowing. By practicing motor onset with a device thatprovides an alternative sensory input to the brain, such as vibrotactilestimulation, the patient can regain volitional swallowing controlreadying them to swallow safely first with their own saliva and later toingest small amounts of food in a controlled volitional fashion. Byproviding volitional control over swallowing the patient can substitutevoluntary swallowing for their loss of reflexive swallowing.

The automatic timer of the systems and devices of the inventions can beused to stimulate the initiation of swallowing on a regular basis toprevent drooling and/or aspiration of the patient's own secretions. Insuch a configuration, a device of the invention is not dependent uponmanual activation by the patient and can be set to initiate swallowingwithout a user input at a predetermined or variable interval. Forexample, the automatic timer can be configured to initiate swallowing ofsaliva to prevent aspiration of secretions from drooling duringsleeping. Methods for automatically stimulating swallowing on a regularbasis or set interval generally comprise applying a device of theinvention to an outside surface of the subject's neck substantially overthe subject's larynx and configuring an automatic timer to activate thevibrotactile stimulator to induce the swallowing reflex. In anembodiment, activation of the vibrotactile stimulator producesvibrations at a frequency of about 40 Hz to about 70 Hz and appliespressure of about 1 psi to about 14 psi to the subject's neck during anonset period. In an embodiment, the onset period comprises about 10 msto about 1.5 s, about 50 ms to about 750 ms, or about 100 ms to about500 ms. In an embodiment, an automatic timer of the device of theinvention is configured to activate the vibrotactile stimulator at aninterval of about 1 to about 5 minutes.

In one embodiment, an automatic timer is configured to activate thevibrotactile stimulator once every 3 minutes to about once every 30minutes for a durations of about 10 ms to about 20 s during which pulsedstimulation is produced at vibrations of about 1 to 300 Hz lasting about200 ms to about 10 s to induce the swallowing reflex, wherein activationof the vibrotactile stimulator is pulsed at a particular rate and lastsfor a particular interval produces vibrations at a frequency of about 40Hz to about 70 Hz and applies pressure of about 1 psi to about 14 psi tothe subject's neck during an onset period.

A device according to the present disclosure can be configured with acounter and timer system to aid in monitoring a patient's use of thedevice. For example, the counter and timer system can be used todetermine or measure frequency of use including how often the patientuses the device, which mode the patient uses, how long and when thedevice is stimulated, and the like. The data generated by the counterand timer system can be used, for example, to determine compliance witha training or therapy regime. Such data can be used to modify atreatment or training program and/or can alert caretakers to a risk ofdrooling or aspiration of secretions due to limited use of the system.

Methods for identifying a subject at risk of aspiration from their ownsecretions generally comprise applying a device of the invention to anoutside surface of the subject's neck substantially over the subject'slarynx; downloading data from the vibrotactile stimulator after a periodof use of the device by the subject; and analyzing to data to determineif the subject is at risk of aspiration from their own secretions due tolimited use. The subject activates the device to induce volitionalswallowing and the device records the data to allow a healthprofessional to determine if the subject is at risk, due to limited use.

Methods for monitoring patient compliance with a training or therapyregime generally comprise applying a device of claim 1 to an outsidesurface of the patient's neck substantially over the patient's larynx,wherein the patient activates the device to induce volitionalswallowing; downloading data from the vibrotactile stimulator after aperiod of use of the device by the patient; and analyzing to data todetermine the patient's compliance with the training or therapy regime.

For dysphagia treatment, a band may be wrapped around the neck, with aninflatable balloon(s) positioned over the larynx. Upon activation (e.g.by a switch, such as a button) by the user (one who wears the device, orunder orders from the wearer) the balloon inflates and puts pressure onthe larynx. A controller box is contemplated that may be set to thestimulus type, the stimulus rate (set or increasing) and amplitude (setor increasing) parameters and whether the duration would be set or stayfor 2 to 6 seconds or as long as the button is pressed. In anembodiment, the device that stimulates the substitute site is a pressureapplying device that attaches to the body by, for example, a Velcro,strap, rubber band, belt, bandage, garment, ace bandage, wire, string,piezoelectric band or film, and/or combination of these or by any othermethod known in the art.

For instance, the stimulating device may include a contact pressurebuilder such as a balloon, inflatable tube that inflates to a desiredpressure or volume. The art of blood pressure monitors includes devicesand methods that may be used as part of the device of the presentinvention. Preferably a neck wrap is used that positions the pressureapplying device to the throat area above the larynx and is adjustablevia VELCRO® or any other adjustment means. A small point such as an areaas small as about 0.02 square centimeter on the throat over the larynxmay be pressed, although larger areas of, for example, about 0.1 toabout 10 cm², about 0.25. to about 5 cm², about 0.5 to about 2.5 cm²areas may be used. A desirable area is a 2 cm circle. In a preferredembodiment, at least about 25%, about 35%, about 50%, about 75%, about85%, about 90%, about 98% or more of the total pressure (calculated asan integrated sum measurement of pressure times surface area) is placedon the throat over the larynx cartilage and not over surrounding muscle.In another embodiment, such selective pressure is achieved, to obtainsatisfactory results. In another embodiment, vibratory energy similarlyis selectively confined on the throat over the larynx versus thesurrounding muscle. In some embodiment, less than about 50%, about 25,about 10%, about 5% or even less pressure is applied to neck muscles. Insome embodiments, the stimulation may be cold, vibration, heat, and/orlow levels of electrical stimulation capable of inducing a sensorystimulus but not high enough to induce muscle contraction, thatcondition or disorders or a combination thereof.

The systems and devices of the present disclosure can be used in methodsfor treating impairment of reflexive swallowing due to intubation. Manypatients are intubated to maintain the airway for ventilation, includingfollowing loss of consciousness due to brain injury or stroke orfollowing coronary artery bypass graft. As the patient recoverscognitive function, extubation of the endotracheal tube occurs. At thispoint it has been found that the swallowing reflex is reduced (deLarminat, Montravers, Dureuil, & Desmonts, 1995). FIG. 3 shows aconceptualization 300 of events post brain injury, placing patients athigh risk of aspiration post extubation with tracheotomy due to reducedafferent stimulation in the upper airway and restricted oral intake,limiting return of reflexive swallowing.

There are most likely several factors contributing reduced swallowingreflex associated with intubation. First, sensory feedback from theupper airway to the brain is reduced due to changes in the sensoryfunction of the mucosa in the upper airway possibly as a result ofinjury to the mucosa by the endotracheal tube, and sensory organs ofnerve endings supplying those organs due to the pressure of theendotracheal tube on the mucosa or resultant edema in the upper airway.In some patients tissue granulation/ulceration occurs when theendotracheal tube has been in place for prolonged periods (over oneweek). Upon extubation such patients often receive a tracheostomy toprovide an adequate airway. It has been shown that during this periodfollowing extubation that the normal swallowing reflex is reduced inpatients increasing their risk of aspiration of their own saliva (deLarminat, Montravers, Dureuil, & Desmonts, 1995).

In addition to loss of the swallowing reflex, when such patients have atracheotomy, their sensory input to the upper airway is further reducedbecause of a lack of air flow through the hypopharynx. In addition, suchpatients are often placed on a restricted oral intake to preventaspiration. As a result of their “nothing per oral” (NPO) status, suchpatients are not swallowing and may be fed through a nasogastric tube orlong-term by enteric means for several days or weeks. All of thesefactors reduce reflexive swallowing. During this period, the methods ofthe invention can enhance volitional swallowing.

The present invention can provide volitional control for patients withmotor control disorders affecting speech and voice. Persons who stutterusually have difficulty with speech initiation and have speech “blocks”when the patient undergoes a loss of volitional control over thelaryngeal muscles in particular. This loss of volitional control ismanifested as delay in voluntary initiation of muscle contraction orvocal fold movement or an interference due to chronic laryngeal musclecontractions or sustained vocal fold closure. Several studies havesuggested that adults who stutter may have increased thresholds tokinesthetic or vibratory stimulation during speech (De Nil & Abbs,1991). The device and methods of the present invention can enhancevibratory sensory input to persons who stutter. Recent research hasshown that persons who stutter have delays in their onset of vocal foldvibration during speech. The present invention increases vibrotactileinput to the central nervous system in persons who stutter therebyenhancing their volitional control for speech. When a mechanicaldisplacement is applied to the larynx according to the methods of theinvention, it stimulates proprioceptors in the strap muscles, producinga reflexive stemothyroid muscle contraction (Loucks et al., 2005).Because extrinsic laryngeal muscles have a high muscle spindle density,stretch or vibratory stimuli applied to the larynx will serve to enhancemuscle activity in this region.

The present invention can provide enhanced volitional control forpatients with Spasmodic Dysphonia and Laryngeal Dystonia. Spasmodicdysphonia is a laryngeal focal dystonia, which produces voiceabnormalities during speech similar to stuttering. These patients haveparticular difficulties initiating voicing during speech (Bielamowicz &Ludlow, 2000; C. L. Ludlow, Baker, Naunton, & Hallett, 1988; C. L.Ludlow & Connor, 1987; C. L. Ludlow, Hallett, Sedory, Fujita, & Naunton,1990) and are often slow to initiate laryngeal muscle activity and haveproblems maintaining vocal fold vibration during speech. Many focaldystonias have associated sensory abnormalities, with reduced corticalresponses in the somatosensory area (Bara-Jimenez, Catalan, Hallett, &Gerloff, 1998; Bara-Jimenez, Shelton, Sanger, & Hallett, 2000) includingspasmodic dysphonia (Haslinger et al., 2005). By providing increasedvibratory stimulation to the laryngeal area according to the methods ofthe invention, input to the cortical somatosensory region will enhancevolitional voice control for speech in persons with spasmodic dysphonia.

In prior methods for treating stuttering, many devices have beendeveloped to provide altered auditory input, auditory masking or delayedor frequency altered feedback of the speaker's speech to them. Examplesinclude the Edinburgh Masker, Delayed Auditory Feedback by Phonic Ear,Pacemaster, the Casa Futura System, the Vocaltech, the Fluency Master®,and SpeechEasy®. The VocalTech® device includes a vibrator applied tothe throat of the user. A microphone picks up the user's voice and thenprovides both an auditory feedback signal and a vibration to the throatto alter feedback during speech.

Various embodiments of the present invention differ both in concept andin function from prior systems in that the patient/user presses a buttonto initiate vibrotactile stimulation to aid their ability to initiatespeech/voice onset. In such embodiments, the vibratory signal isinitiated before the patient attempts to initiate speech and will aid intheir volitional control of speech initiation. The VocalTech® device forexample only detects speech after it has started and can only betriggered by the patient/user's own speech. The VocalTech® deviceutilizes a feedback of the patient/user's speech and no other inputs.Therefore if the patient is unable to initiate speech and/or voice, thevibratory signal cannot be initiated. The lack of initiation of thevibratory signal is further exacerbated as there is a delay between theonset of the patient's speech and the onset of the vibratory andauditory feedback. Therefore the VocalTech® device is unable to enhancethe patient's ability to onset speech as it is dependent upon thespeaker being able to initiate speech. In contrast, the device and thesystem of the present disclosure assists patients with speech initiationas the vibratory stimulus precedes the person's speech initiation byenhancing mechanical sensory input to cortical control centers forspeech. Other auditory masking or delayed or frequency altered feedbackdevices such as SpeechEasy® also alter or delay the speaker's acousticspeech signal and also require that the speaker is able to initiatespeech before the feedback can occur. Therefore these other devicesdiffer both in concept and function from the present invention.

In one embodiment, the present invention is a portable device that canbe supplied to adults who stutter and persons with dysphonia to providestimulation before speech to enhance triggering and controlling voiceonset and maintenance for speech. The device of the present disclosurecan be used in everyday speaking situations. Patients could purchase thedevice to use in everyday life to enhance volitional control whilespeaking.

C. Kits

The present disclosure also relates to kits that include at least onestimulating device of the present disclosure, a container for thedevice, and instructions for using the device. In an embodiment, the kitcomprises a device of the invention that is adapted to be placed incontact with an affected body part, such as the larynx, a container forthe device, a switch activated by a patient, and instructions for usingthe device. The instructions desirably include at least one instructioncorresponding to one or more method steps disclosed herein. In anembodiment, a power supply such as a battery is contained within thestimulating device. In an embodiment, disposable covers are includedthat cover the stimulator during use. In an embodiment the stimulatingdevice includes at least one pump that increases pressure within achamber such as balloon(s) or tube(s). The device further may include apressure, stretch, volume, power or other sensor to monitor pressureexerted by the device. In an embodiment the device further includes aswitch for setting the amount of desired pressure or movement and/or lowlevels of electrical stimulation on the skin to increase sensation inthe skin in the region overlying the larynx. Switches also may exist forsetting frequency and or amplitude of the stimulation.

EXAMPLE

The present disclosure may be better understood with reference to thefollowing example. This example is intended to further illustrate theinvention and its underlying principles but is not intended to limit thescope of the invention. Various modifications and changes may be made tothe embodiments described above without departing from the true spiritand scope of the disclosure.

Example 1

This example demonstrates that low levels of sensory stimulation to thethroat area in patients with severe chronic pharyngeal dysphagiaenhances their ability to swallowing safely while high levels ofelectrical stimulation that activate throat muscles do not enhanceswallowing in these patients.

Although surface electrical stimulation has received increased attentionas an adjunct to swallowing therapy in dysphagia in recent years (Freed,Freed, Chatbum, & Christian, 2001; Leelamanit, Limsakul, & Geater, 2002;Park, O'Neill, & Martin, 1997; Power et al., 2004), little is knownabout the effects of transcutaneous stimulation on swallowingphysiology. It has been hypothesized that electrical stimulation mayassist swallowing either by augmenting hyo-laryngeal elevation (Freed,Freed, Chatburn, & Christian, 2001; Leelamanit, Limsakul, & Geater,2002) or by increasing sensory input to the central nervous system toenhance the elicitation of swallowing (Park, O'Neill, & Martin, 1997;Power et al., 2004).

When electrical stimulation is applied to the skin or oral mucosa at lowcurrent levels it activates the sensory nerve endings in the surfacelayers providing sensory feedback to the central nervous system. Withincreased current amplitude, the electric field may depolarize nerveendings in muscles lying beneath the skin surface (Loeb & Gans, 1986)and may spread with diminishing density to produce muscle contraction.

When electrodes are placed in the submental region, therefore, thecurrent density is greatest at the skin surface, and diminishes withdepth through the platysma underlying the skin and subcutaneous fat(Sobotta, 1990). Accordingly, as the current is increased in amplitude,increasingly deeper muscles may be recruited, albeit with lessefficiency. Such muscles include the anterior belly of the digastric,which can either lower the mandible or pull the hyoid upward dependingupon whether the mouth is held closed. Deeper still are the mylohyoidand geniohyoid muscles, which pull the hyoid bone upward and toward themandible, respectively. These muscles are much less likely to beactivated by surface stimulation, however, because of their greaterdepth.

Similarly when electrodes are placed on the skin overlying the thyroidcartilage in the neck, the current will be greater at the skin with lessintensity to the underlying platysma muscle with further reduction tothe underlying sternohyoid and omohyoid muscles (Sobotta, 1990), whichpull the hyoid downward and backward towards the stemum. The electricalfield strength would be even further diminished if it reaches the deeperthyrohyoid muscle, which brings the larynx and hyoid together and thestemothyroid muscle, which lowers the larynx towards the sternum. Giventhat the stemohyoid muscle is larger and overlies the thyrohyoid andstemothyroid, we previously found that high levels of surface electricalstimulation on the neck could pull the hyoid downward interfering withthe ability of normal volunteers to raise the larynx toward the hyoidbone as occurs in normal swallowing (Humbert et al., 2006). In fact, insome healthy volunteers high intensity surface electrical stimulationreduced swallowing safety as it allowed liquid to enter the vestibule(Humbert et al., 2006).

In VitalStim® Therapy (Wijting & Freed, 2003) electrodes aresimultaneously activated over the submental and laryngeal regions on thethroat, with the aim of producing a simultaneous contraction of themylohyoid in the submental region (to elevate the hyoid bone) and thethyrohyoid in the neck (to elevate the larynx to the hyoid bone).However, because these muscles lie deep beneath the anterior belly ofthe digastric, sternohyoid and omohyoid muscles, we hypothesized thatsimultaneous transcutaneous stimulation with two pairs of electrodes atrest would cause: 1) the hyoid bone to descend in the neck (due tosternohyoid muscle action); 2) the hyoid bone to move posteriorly (dueto the omohyoid muscle activity); and, 3) the larynx to descend (ifcurrent activates either the sternohyoid or stenothyroid muscles).Further, we hypothesized that in severe chronic dysphagia: 4) when thesame array is used at low levels of stimulation just above the sensorythreshold, sufficient for sensation but without muscle activation,patients' swallowing might improve due to sensory facilitation; while 5)at higher levels required for motor stimulation, the descent of thehyoid might interfere with swallowing causing increased penetration andaspiration.

Methods

Participant selection criteria included: chronic stable pharyngealdysphagia, at risk for aspiration for 6 months or more, a score of 21 orgreater on the Mini-Mental State Examination (Folstein, Folstein, &McHugh, 1975), a severely restricted diet and/or receiving nutritionthrough enteric feeding, and medically stable at the time of the study.To be included for study, all participants had to demonstrate a risk ofaspiration for liquids on videofluoroscopy during the screening portionof the study.

Procedures

Participants were administered informed consent, and had to correctlyanswer 10 questions to demonstrate that they understood the content ofthe consent before participating. VitalStim® electrodes (ChattanoogaGroup, Hixson, Tenn., #59000) and the VitalStim® Dual Channel Unit wereused for the study. Two sets of electrodes were used; the top set wasplaced horizontally in the submental region over the region of themylohyoid muscle above the hyoid bone (FIG. 16). The bottom set wasplaced on the skin over the thyroid cartilage on either side of themidline over the region of the thyrohyoid muscle medial to thesternocleidomastoid muscle. This electrode array was recommended aseffective during certification training of the first two authors(Wijting & Freed, 2003). A ball bearing with a diameter of 19 mm wastaped to the side of the neck for measurement calibration.

After familiarizing the participant with the device, the sensorythreshold, which was the lowest current level at which the participantreported a “tingling” sensation on the skin, was identified. Stimulationat the sensory threshold level did not produce movement onvideofluoroscopic recordings and was the lowest level at whichparticipants sensed the stimulation on the skin. Movement was firstobserved when participants first reported a “tugging” sensation, usuallyaround 7 or 8 mA. The maximum motor level was the highest current levela participant could tolerate without discomfort during stimulation onthe neck. The sensory and motor levels independently for each set ofelectrodes was determined. The VitalStim® device cycles automaticallyfrom “on” to “off” to “on” again for 1 second every minute. Because thechange in stimulation is ramped, this cycling process takes up to 4 s.For the stimulation at rest trials, the participant was told to keeptheir teeth clenched to prevent jaw opening and the stimulation wassimultaneously set at the maximum tolerated levels for both sets ofelectrodes. When the stimulation duration reached 55 s, videofluoroscopywas turned on and we recorded the fluoroscopic image on S-VHS videotapewhile the participant was in the resting position and the deviceautomatically cycled from “on”, to “off” and then “on” again. Theexaminer pressed a button at the time of stimulation offset to place avisible marker on the videotape.

During the videofluoroscopic screening examination, we determined whichvolume, either a 5 or 10 ml of liquid barium bolus, was more challengingand put a participant at risk of aspiration for use during testing.During testing, between one and three swallows were recorded in each ofthe following conditions in random order: 1) with no stimulation, 2)with both electrode sets on at the sensory threshold level and 3) withboth sets at the maximum tolerated stimulation level. Stimulationremained on before, during and after the stimulated swallows. Thevideotaped recordings included an auditory channel for documentation anda frame counter display for identifying when stimulation changed.

Because radiation exposure during this study was administered forresearch purposes only and was not for necessary medical care, theRadiation Safety Committee limited us to a short exposure time perparticipant for the total study. Therefore, depending on radiationexposure time in each part of the study, we were only able to conductbetween one and three trials per condition in addition to stimulation atrest for each of the participants.

Movement Analysis

The video of each trial was captured off-line using Peak Motus 8, a 2Dmotion measurement system (ViconPeak, Centennial, Colo. 80112). Thesystem was equipped with a video capture board at −60 fields/s (−30frames/s) and a frame size of 608×456 pixels. The radius of the ballbearing (9.5 mm) was used for all measurement calibrations in thehorizontal and vertical directions. An investigator used a cursor toidentify the points on the most anterior-inferior corner of the secondand fourth vertebra on each video frame and a straight line was drawnbetween these two points to define the y axis. When either the second orfourth vertebra was not visible, the bottom anterior-inferior corner ofthe first and third vertebrae were used in the same fashion. A lineperpendicular to the y axis at the anterior-inferior corner of the lowervertebra served as the x axis. The x and y coordinates for all pointswere determined in mm relative to the anterior-inferior corner of thesecond vertebra serving as the origin with anterior and superior pointsbeing positive and posterior and inferior points being negative fordirection of movement of the hyoid. Four points were marked for eachframe, the anterior-inferior points of the two interspersed vertebrae,the anterior inferior point of the hyoid bone and the most posterior andsuperior point in the subglottal air column (to track the position ofthe larynx).

The time series plots of the x and y points of the hyoid bone and the ycoordinate of the larynx were exported from Peak Modus into MicrosoftExcel and then into Systat 11 (Systat Software, Inc., Richmond, Calif.)for analysis. The frame when the stimulation cycled from “on” to “off”was added to the file and used to sort measures into stimulation “on”and stimulation “off”. All of the position data were then corrected toplace the starting position at zero on both the x and y axes for eachsubject and then the mean hyoid (x,y) and larynx (y) positions werecomputed for the stimulation “on” and stimulation “off” conditions foreach subject.

Dysphagia Ratings

Four experienced certified speech pathologists initially examined thescreening videotapes of randomly selected subjects to decide on a ratingsystem. After assessing several swallows with the RosenbekPenetration-Aspiration Scale (Rosenbek, Robbins, Roecker, Coyle, & Wood,1996) (Pen-Asp) it was noted that many of the participants who were onenteric feeding because of their risk of aspiration could score withinthe normal range, a score of 1 on this scale. This occurred when nopenetration or aspiration occurred even though there was severe residualpooling in the pyriform sinuses and none of the bolus entered theesophagus. These participants regurgitated any residual material backinto the mouth after a trial, not swallowing any of the liquid butscoring as normal because no material entered the airway. Because scoresof 1 on the Pen-Asp scale were at ceiling (normal) and would not allowmeasurement of improvement, this scale could only measure a worsening inswallowing in these patients. Therefore, another scale was developedthat did not have a ceiling effect.

The NIH Swallowing Safety Scale (SSS) captured the abnormalities seen inthis patient group, which involved pooling and a lack of esophagealentry with and without penetration and aspiration. When scoring aswallow, a score of 1 was assigned for the occurrence of each thefollowing abnormalities: pooling in the vallecula, penetration into thevestibule from the hypopharynx, pooling in the pyriform, and back uppenetration from the pyriform into the laryngeal vestibule. The amountof the bolus material entering and clearing from the upper esophagus wasrated as 3 if none entered, 2 if a minimal amount entered, 1 if amoderate amount entered and 0 if all of the bolus was cleared throughthe upper esophagus. In addition, the total number of aspirations ineach swallowing sample were counted. Only normal swallows received atotal of 0 on this scale and the maximum score could reach as high as 13depending upon the number of aspirations or other abnormalities in bolusflow that occurred in a single swallow.

All four speech pathologists viewed each videofluoroscopic recordingwithout knowledge of condition and came to a consensus on all notedbehaviors and the Pen-Asp rating before assigning the scores. Afterrepeating ratings on 21 trials to establish reliability, differences inratings of the same swallow were noted and a set of uniform rules weredeveloped to be followed in assigning scores. These rules weresubsequently used to assign ratings to each of the trials in this study.Another set of 18 trials was then repeated to determine the measurementreliability.

Statistical Analyses

To determine the reliability of the position measures, two examinersmeasured the position for the hyoid on the x and y axes and larynx onthe y axis on each frame and then computed means for each during boththe stimulated and non-stimulated conditions on 4 of the 10 subjects.The output of the General Linear Model Systat 11 (Systat Software, Inc.,Richmond, Calif.) was used to calculate the mean square differences forthe within and between subject factors. The Intraclass CorrelationCoefficient (ICC) was computed by taking the mean square differencebetween subjects and subtracting the mean square difference withinsubjects and then dividing the result by the sum of the mean squaredifference between subjects and the mean square difference withinsubjects (Fleiss, 1999).

To determine the reliability of the ratings made using the Pen-Asp Scaleand the NIH-SSS, ICCs were computed between the two sets of ratings oneach scale from the first 21 trials that were reanalyzed. To identifythe items that were unreliable, Cohen's Kappa was computed for the twosets of ratings of each component item of the NIH-SSS using Systat 11(Systat Software, Inc., Richmond, Calif.). After developing rules forscoring those items that had low reliability, ICCs were computed on thesecond set of repeated ratings for both the Pen-Asp Scale and theNIH-SSS.

To address the first hypothesis that the hyoid bone would descend in theneck with maximal levels of stimulation at rest, a one-sampledirectional t-test was used to test for a lowering of the hyoid bone onthe y axis between “off” and “on” stimulation. To address the secondhypothesis that the hyoid bone would move posteriorly, a one-sampledirectional t-test was used to test for a retraction of the hyoid boneon the x axis in the “off” and “on” stimulation conditions withinsubjects. To determine if the larynx descended during stimulation, aone-sample directional t-test was used to test for a lowering of thesubglottal air column between the two conditions.

To determine if swallowing improved due to sensory levels ofstimulation, one-sample directional t-tests were used to testparticipants' mean changes in ratings between non-stimulated swallowsand stimulated swallows within participants on the Pen-Asp scale and theNIH-SSS with a Bonferroni corrected p value of 0.05/2=0.025. Finally, todetermine if swallowing worsened during maximum levels of motorstimulation, one-sample directional t-tests were used to testparticipants' mean changes in ratings between non-stimulated swallowsand stimulated swallows within participants on the Pen-Asp Scale and theNIH-SSS with a Bonferroni corrected p value of 0.05/2=0.025. Pearsoncorrelation coefficients using a Bonferroni corrected p value of 0.025for statistical significance were computed between both theparticipant's mean initial severity on the Pen-Asp scale and the NIH-SSSand changes in mean ratings during the sensory stimulation to determineif participant characteristics predicted the degree of benefit.Similarly, Pearson correlation coefficients were computed between theextent to which the hyoid was pulled down in the neck during stimulationat rest and the change in participants' mean ratings for swallowing onthe Pen-Asp scale and the NIH-SSS using a Bonferroni corrected p valueof 0.025 for statistical significance.

Results

1. Participants

All 11 participants had chronic long-standing dysphagia (Table 1). Theirdisorder was either subsequent to a CVA in six (>6 months post), postcraniotomy for a benign tumor in two (2 and 4 years post) or posttraumatic brain injury in two (2 and 3 years post). Only one patient hada chronic progressive neurological disease, Parkinson disease of >20years with dysphagia for more than 2 years duration.

Ten of the 11 participants participated in the stimulation at resttrials; one did not because of time constraints. During swallowstimulation trials, one of the participants had severe aspiration on aninitial swallowing trial and for safety reasons the study wasdiscontinued for that participant. Therefore, we were able to includeten participants in the motor stimulation swallow trials. Because oftime constraints, two of the participants did not participate in the lowsensory levels of stimulation, leaving 8 participants in the study.

2. Measurement Reliability

The ICC for the movement of the hyoid bone on the y axis in the on andoff stimulation conditions were 0.99 and 0.94 respectively and for hyoidmovement on the x axis were 0.94 and 0.87. The ICCs for the larynx onthe y axis in the stimulation “on” and “off” positions were 0.58 and0.66 respectively indicating much less reliability on these measures.Because the movement of the larynx was extremely small, ranging from amean position of 0.4 mm in the stimulation “on” to 0.18 mm in the “off”condition, measurement variability contributed to the variance on thismeasure.

3. Movement Induced by Stimulation at Rest

To address the first hypotheses, a one-tailed directional t-testcomparing the mean position between “off” and “on” stimulationconditions demonstrated a significant lowering of the hyoid position onthe y axis (f=−2.523, o7=9, p=0.016) (see FIG. 16). In FIG. 17 theindividual tracings of hyoid movement in each of the patients is shownwhen the stimulator is turned “on” and then “off” and then “on” againshowing elevation of the hyoid bone when the stimulator is turned “off”.To address the second hypothesis that the hyoid bone would moveposteriorly with stimulation at rest, a directional t-test comparing themean positions in the “off” and “on” stimulation conditions withinsubjects was not significant (P=−0.102, αf/=9, p=0.460). Similarly, adirectional t-test found no descent in laryngeal position on the y axisduring stimulation (£=0.696, d/=9, p=0.748).

4. Reliability of Ratings on the Pen-Asp and NIH SSS

After the first set of 21 repeated ratings, the ICC was 0.965 on thePenAsp scale and 0.764 on the NIH-SSS. Because of concerns about thereliability of the NIH-SSS, we implemented more detailed judging rulesfor each item where disagreement occurred. A second set of 18reliability measures using the new judging rules resulted in an ICC forthe NIH-SSS that was 0.925, demonstrating adequate reliability whenusing the scale once the judging rules were developed and implemented.

5. Effects of Low Sensory Stimulation Levels During Swallowing

Due to time constraints only eight of the ten participants completed thesensory condition. To address the fourth hypothesis that swallowingimproved with sensory levels of stimulation, one-sample directionalt-tests were computed to compare mean change in ratings betweennon-stimulated swallows and stimulated swallows within participants. Theresults were not significant on the Pen-Asp Scale (£=0.336, cf/=7,p=0.373) but were significant on the NIH-SSS (.=.2.355, df=7, p=0.025)using a Bonferroni corrected p value of 0.05/2=0.025. This is shown inFIG. 18. Six of the eight of the participants showed a reduction on theNIH-SSS with sensory stimulation during swallowing while five of theeight participants showed a reduction on the Pen-Asp scale.

6. Effects of Motor Stimulation Levels During Swallowing

To address the fifth hypothesis that the risk for aspiration andswallowing safety worsened during stimulation, one-sample directionalt-tests were computed to examine mean change in ratings betweennon-stimulated swallows and stimulated swallows within participants. Theresult was not significant on either the Pen-Asp Scale (/=0.363, d/=9,p=0.637) or on the NIH-SSS (/=−0.881, d/=9, p=0.201) at a Bonferronicorrected p value of 0.05/2=0.025. On the NIH-SSS scale, five of the tenparticipants had increased risk with motor levels of stimulation (FIG.19), while on the Pen-Asp equal numbers of participants increased ordecreased with motor levels of stimulation (FIG. 20).

7. Relationship Between Severity of Dysphagia and Changes in Swallowingwith Stimulation

The Pearson correlation coefficient between participants' initialseverity on the Pen-Asp scale and change in swallowing with sensorystimulation was not significant (/=0.142, p=0.737). Similarly,participants' initial severity and change in swallowing with sensorystimulation on the NIH-SSS (/=0.701, p=0.053) was not significant usinga Bonferroni corrected a value of 0.025 for statistical significance. APearson correlation coefficient between both the participants' initialseverity on the Pen-Asp scale and change in swallowing with motorstimulation was not significant (/=−0.501, p=0.140), nor was thecorrelation between participants' initial severity on the NIH-SSS andchange in swallowing with motor stimulation (/=−0.190, p=0.599), using aBonferroni corrected a value of 0.025 for statistical significance.

8. Relationship of Movement during Stimulation at Rest with Changes inSwallowing with Stimulation

Pearson correlation coefficients were computed between the extent towhich the hyoid was pulled down in the neck during stimulation at restand the change in swallowing on the Pen-Asp and the NIH-SSS using aBonferroni corrected o value of 0.025 for statistical significance. Nosignificant relationship was found between the degree of improvement onthe NIH-SSS and the degree to which the hyoid bone was depressed duringmotor levels of stimulation at rest (r=−0.388, n=9, P=0.302). Theimprovement in the Pen-Asp scale during motor stimulation wassignificantly inversely related to the degree to which the hyoid bonewas depressed during motor levels of stimulation at rest (r=−0.828, n=9,p=0.006). The relationship demonstrated that those with the greatesthyoid depression at rest had the greatest reduction on the Pen-Asp scaleduring motor levels of stimulation while swallowing.

Discussion

One purpose of this study was to determine the physiological effects ofsurface electrical stimulation on the position of the hyoid and larynxin the neck. We had predicted that when both the submental and laryngealelectrode pairs were stimulating at the participants' maximal toleratedlevels, that the hyoid bone would be pulled downward, most likely due tostimulation of the sternohyoid muscle. The data supported thishypothesis; all but two of the participants had depression of the hyoidbone by as much as 5 to 10 mm during stimulation at rest (FIGS. 6A and6B). We also predicted that the hyoid bone might be pulled posteriorly;however, limited anterior-posterior movement occurred in the hyoid bone.Three participants had hyoid anterior movement, by as much as 5 mm inone case, while the others had minimal movement in the posteriordirection. Whereas minimal ascending movement (2-3 mm) occurred in thelarynx in two participants, none of the other participants experiencedany appreciable laryngeal movement (FIG. 6D) and the 2-3 mm changes werepotentially due to measurement variation. To summarize these findings,the only appreciable motoric effects of surface electrical stimulationwas to cause the hyoid bone to descend in the neck, producing movementin the opposite direction from that required for swallowing.

These results suggest that when surface stimulation was applied to theneck at rest, stimulation was either too weak or not deep enough tostimulate axons innervating the muscles that produce hyoid and laryngealelevation such as the mylohyoid and the thyrohyoid muscles respectively.No change in laryngeal position was observed with surface stimulation atrest.

Another purpose of this study was to determine the immediate effects ofsurface stimulation on swallowing in participants with chronicpharyngeal dysphagia. Based on previous use of sensory stimulation inthe oral and pharyngeal cavities to augment patients' volitional controlof swallowing (Hamdy et al., 2003; Park, O'Neill, & Martin, 1997), wecompared sensory levels of electrical stimulation just above theparticipants' sensory threshold for detecting a tingling sensation onthe skin, and found a significant improvement during swallowing on theNIH-SSS scale (FIG. 18). The improvement on the NIH-SSS tended to berelated to higher initial scores; that is the more severely affectedpatients were those who had the greatest improvement with stimulation.Because the NIH-SSS captures pharyngeal pooling and failed esophagealentry in contrast with the Pen-Asp scale, which only measures aspirationand penetration, sensory stimulation may be somewhat helpful in thosepatients who have reduced ability to clear the bolus from the airway.

Based on the expected lowering of the hyoid with motor levels ofstimulation, we hypothesized that the group would have increasedpenetration and aspiration during swallowing with motor stimulation. Nogroup change in aspiration was noted on either scale with motor levelsof stimulation. When the degree of improvement on the Pen-Asp scale withmotor levels of stimulation was examined relative to the degree of hyoiddepression, we found an unexpected relationship indicating that patientswith the greatest hyoid depression during motor levels of stimulation atrest had the greatest improvement during swallowing with the same levelsof stimulation. When the hyoid was depressed with stimulation, a patientprobably experienced a greater resistance to hyo-laryngeal elevationduring swallowing. Perhaps those patients who felt a greater downwardpull on the hyoid, when stimulation was turned on at maximal levels,made a greater effort to elevate the hyo-laryngeal complex whenswallowing in an attempt to overcome the effects of the stimulation. Itcould also be the case that those patients who had greater residualpower in their hyo-laryngeal muscles would have not only experiencedgreater hyoid descent with stimulation but could also have greaterresidual power that they could recruit for hyo-laryngeal elevation tocounteract the stimulation induced descent during swallowing.

This study also addressed the immediate physiological effects of the useof surface electrical stimulation at rest and during swallowing. Thisstudy suggests that electrical stimulation should be used judiciouslydependent upon a patient's type and degree of difficulty withswallowing. In those patients who already have some ability to raise thehyo-laryngeal complex, hyoid depression with stimulation may serve as“resistance” during therapy. On the other hand, if a patient is unableto produce any hyo-laryngeal elevation, and therefore would not be ableto resist the hyoid depression induced by stimulation, stimulation mightput such a patient at greater risk of aspiration as the hyo-laryngealcomplex is held down during swallowing. This may have occurred in someof the more severely affected patients who increased in severity on thePen-Asp and NIH-SSS with motor levels of stimulation, while those lessimpaired did not change (FIGS. 19 and 20).

In this study, both submental and laryngeal pairs of electrodes wereused simultaneously as is recommended for VitalStim® Therapy. It islikely that the simultaneous stimulation resulted in hyoid loweringbecause the stronger stimulation to the more superficial and largersternohyoid and sternothyroid muscles overcame any action that mighthave been induced by stimulation of the mylohyoid muscle in thesubmental region or the thyrohyoid muscle beneath the sternohyoid in thethroat region. Some have proposed using submental stimulation alone toactivate the anterior belly of the digastric and the mylohyoid musclesto pull the hyoid bone upward. However, elevation of the hyoid bonewithout simultaneous stimulation of the thyrohyoid to raise the larynxwould leave the larynx down resulting in further opening of thevestibule and increased risk of aspiration. Only if the mylohyoid andthyrohyoid muscles are activated together, without contraction of thesternohyoid, would both the hyoid and larynx be raised together as haspreviously been shown with intramuscular stimulation (Burnett, Mann,Cornell, & Ludlow, 2003). This cannot be achieved using surfacestimulation, because the larger sternohyoid muscle overlies thethyrohyoid and pulls the hyoid downward.

The finding that the group as a whole improved with sensory levels ofstimulation alone on the Pen-Asp scale was unexpected. Previous researchhas shown that stimulation of the anterior and posterior faucial pillarswas most effective stimulation for eliciting a swallow reflex in normalpersons (Pommerenke, 1927). Although not studied physiologically,stroking the throat region is known to assist with the spontaneouselicitation of swallowing in infants and some mammals. Stimulation ofeither the glossopharyngeal or the superior laryngeal nerves has beenshown to elicit swallowing in animals (Jean, 1984) and bilateralchemical blockade of the superior laryngeal nerves disrupts swallowingin normal humans (Jafari, Prince, Kim, & Paydarfar, 2003). It has notbeen observed that sensory stimulation to the surface of the throatwould reflexively trigger a swallow in adults; however, sensory levelsof electrical stimulation on the skin in the throat may facilitatevolitional triggering of swallowing in dysphagia. These results suggestthat low levels of electrical stimulation on the skin might bebeneficial in some patients. Because such low levels of electricalstimulation were not observed to induce hyoid depression, we posit thatnone of the patients would be put at increased risk for aspiration usinglower sensory levels of stimulation. Before surface electricalstimulation is used, the patients should be carefully screened todetermine whether they would be placed at increased risk of aspirationwith a procedure that lowers the hyoid.

TABLE 1 Participant Characteristics and Surface Electrical StimulationLevels Sensory Motor Time post Threshold Threshold onset Upper/LowerUpper/Lower Subject Sex Age Etiology (years) Status Electrode (mA)Electrode (mA) 1. M 66 hemmorrhage in 2.5 PEG, bilateral sensory 3.5/2.08.0/8.0 veterbrobasilar loss, pooling, previous circulation aspirationpneumonia 2. M 66 Parkinson 20 years PEG for 2 years, 6.0/2.5 10.0/10.0disease duration, swallowed own Severe secretions dysphagia Recurrentpneumonias 2+ years 3. M 76 Stroke 1 PEG unable to handle 4.0/2.0 14/7.0 secretions Aspriation pneumonia X 3, normal sensation 4. M 78Brain stem 5 PEG, frequent 7.0/7.0 14/14 stroke aspiration pneumonias,sever reductions in UES relaxation, normal sensation 5. F 47 Leftoccipital 3 PEG, unable to handle 3.0/4.0 10/10 and brain stemsecretions stroke Bilateral sensory loss 6. M 25 closed brain 2Aspirations on liquids, 3.5/6.0 16.6/13.0 surgery bilateral sensory loss7. M 48 Cerebellar 2 PEG, Unable to handle 3.0/2.5 18.0/18.0 hemorrhagewith secretions, aspiration craniotomy pneumonia, pooling, Normalsensation 8. F 44 Subarchnoid 2 Tracheostomy 4.0/2.0 12.5/9.5 hemorrhage left PEG tube vertebral artery Normal sensation bilateralPooling of secretions 9. M 45 Traumatic brain 3 Chokes on saliva, eats3.0/4.0 18.0/16.0 injury soft foods, drooling, Bilateral sensory loss10. M 61 Left hemisphere .5 PEG, Inable to handle 1.5/4.0 13.0/13.0stroke secretions, Normal sensation on left, pooling, BOTOX  ® in UES11. M 47 Craniotomy for 4 Severe aspiration,  1.5/1.5* 14/18 brain stemtumor multiple aspiration pneumonias Bilateral sensory loss *Couldn'tstudy effects of either sensory or motor stimulation during swallowingdue to severe aspiration.

REFERENCES

References not listed specifically can be found in the literature by asearch for the authors. U.S. application Ser. No. 10/529,401 entitledMethods and Devices for Intramuscular Stimulation of Upper Airway andSwallowing Muscle Groups filed on Mar. 28, 2005, is incorporated byreference in its entirety. The references found in that patentapplication are relevant and incorporated by reference with respect tothe details of stimulating devices and method which are contemplated foruse in embodiments presented here.

All references cited herein are hereby incorporated by reference intheir entirety.

-   Aviv, J. E., Martin, J. H., Sacco, R. L., Zagar, D., Diamond, B.,    Keen, M. S., et al. (1996). Supraglottic and pharyngeal sensory    abnormalities in stroke patients with dysphagia. Ann Otol    Rhinol.Laryngol., 105, 92-97.-   Aviv, J. E., Sacco, R. L., Mohr, J. P., Thompson, J. L., Levin, B.,    Sunshine, S., et al. (1997). Laryngopharyngeal sensory testing with    modified barium swallow as predictors of aspiration pneumonia after    stroke. Laryngoscope, 107, 1254-1260.-   Aviv, J. E., Sacco, R. L., Thomson, J., Tandon, R., Diamond, B.,    Martin, J. H., et al. (1997). Silent laryngopharyngeal sensory    deficits after stroke. Ann Otol Rhinol. Laryngol., 106, 87-93.-   Bara-Jimenez, W., Catalan, M. J., Hallett, M., & Gerloff, C. (1998).    Abnormal somatosensory homunculus in dystonia of the hand. Ann    Neurol, 44 {5), 828-831.-   Bara-Jimenez, W., Shelton, P., Sanger, T. D., & Hallett, M. (2000).    Sensory discrimination capabilities in patients with focal hand    dystonia. Ann Neurol, 47(3), 377-380.-   Bielamowicz, S., & Ludlow, C. L. (2000). Effects of botulinum toxin    on pathophysiology in spasmodic dysphonia. Ann Otol Rhinol Laryngol,    109, 194-203.-   Burnett, T. A., Mann, E. A., Cornell, S. A., & Ludlow, C. L. (2003).    Laryngeal elevation achieved by neuromuscular stimulation at rest. J    Appl Physiol, 94(1), 128-134.-   Burnett, T. A., Mann, E. A., Stoklosa, J. B., & Ludlow, C. L.    (2005). Self-triggered functional electrical stimulation during    swallowing. J Neurophysiol, 94(6), 4011-4018.-   Conforto, A. B., Kaelin-Lang, A., & Cohen, L. G. (2002). Increase in    hand muscle strength of stroke patients after somatosensory    stimulation. Ann Neurol, 57(1), 122-125.-   de Larminat, V., Montravers, P., Dureuil, B., & Desmonts, J. M.    (1995). Alteration in swallowing reflex after extubation in    intensive care unit patients. Crit Care Med, 23(3), 486-490.-   De Nil, L. F., & Abbs, J. H. (1991). Kinaesthetic acuity of    stutterers and non-stutterers for oral and non-oral movements.    Brain, 114, 2145-2158.-   Dick, T. E., Oku, Y., Romaniuk, J. R., & Cherniack, N. S. (1993).    Interaction between central pattern generators for breathing and    swallowing in the cat. J Physiol, 465, 715-730.-   Dubner, R., Sessle, B. J., & Storey, A. T. (1978). The Neural Basis    of Oral and Facial Function. New York: Plenum Press.-   Fleiss, J. L. (1999). The design and analysis of clinical    experiments. New York, N.Y.: John Wiley & Sons, Inc.-   Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975).    “Mini-mental state”. A practical method for grading the cognitive    state of patients for the clinician. J Psychiatr Res, 72(3),    189-198.-   Fraser, C₁ Rothwell, J., Power, M., Hobson, A., Thompson, D., &    Hamdy, S. (2003). Differential changes in human pharyngoesophageal    motor excitability induced by swallowing, pharyngeal stimulation,    and anesthesia. Am J Physiol Gastrointest Liver Physiol, 285(1),    G137-144.-   Freed, M. L., Freed, L., Chatburn, R. L., & Christian, M. (2001).    Electrical stimulation for swallowing disorders caused by stroke.    Respir Care, 46(5), 466-474.-   Hägg. M & Larsson, B. (2004) Effects of motor and sensory    stimulation in stroke patients with long-lasting dysphagia.    Dysphagia, 19: 219-230.-   Hamdy, S., Jilani, S., Price, V., Parker, C, Hall, N., & Power, M.    (2003). Modulation of human swallowing behaviour by thermal and    chemical stimulation in health and after brain injury.    Neurogastroenterol Motil, 75(1), 69-77.-   Haslinger, B, Erhard, P., Dresel, C., Castrop, F., Roettinger, M.,    Ceballos-Baumann, A O. “Silent event-related” fMRI reveals reduced    sensorimotor activation in laryngeal dystonia. Neurology, 65:    1562-15-   Holzer SE, and Ludlow, CL. (1996) The swallowing side effects of    botulinum toxin type A injection in spasmodic dysphonia.    Laryngoscope, 106: 88-92.-   Humbert I, Lynch J, Ludlow, CL. Estimating the prevalence of chronic    pharyngeal dysphagia in neurological disorders., in preparation    2008.-   Humbert I A, Poletto C J, Saxon K G, Kearney P R, Crujido L.,    Wright-Harp, W., Payne, J., Jeffries, N, Sonies, BC,    Ludlow CL. (2006) J. Appl. Physiology 101: 1657-1663-   Jafari, S., Prince, R. A., Kim, D. Y., & Paydarfar, D. (2003).    Sensory regulation of swallowing and airway protection: a role for    the internal superior laryngeal nerve in humans. J Physiol, 550(Pt    1), 287-304.-   Jean, A. (1984). Control of the central swallowing program by inputs    from the peripheral receptors. A review. J Auton Nerv Syst, 10,    225-233.-   Leelamanit, V., Limsakul, C₁ & Geater, A. (2002). Synchronized    electrical stimulation in treating pharyngeal dysphagia.    Laryngoscope, 112(12), 2204-2210.-   Loeb, G. E., & Gans, C. (1986). Electromyography for    Experimentalists. Chicago: The University of Chicago.-   Logemann, J. A. (1993). Noninvasive approaches to deglutitive    aspiration. Dysphagia, 8(4), 331-333.-   Logemann, J. A., Pauloski, B. R., Colangelo, L., Lazarus, C, Fujiu,    M., & Kahrilas, P. J. (1995). Effects of a sour bolus on    oropharyngeal swallowing measures in patients with neurogenic    dysphagia. J Speech Hear Res, 38(3), 556-563.-   Logemann, J. A. (1998). Evaluation and treatment of swallowing    disorders (2nd ed.). Austin, Tex.: Pro-Ed.-   Loucks, T. M., Poletto, C. J., Saxon, K. G., & Ludlow, C. L. (2005).    Laryngeal muscle responses to mechanical displacement of the thyroid    cartilage in humans. J Appl Physiol, 99(3), 922-930.-   Lowell S Y, Poletto C J, Knorr-Chung B R, Reynolds R C, Simonyan K,    Ludlow C L (2008). Sensory stimulation activates both motor and    sensory components of the swallowing system. NeuroImage, 42:    285-295.-   Ludlow, C. L., Baker, M., Naunton, R. F., & Hallett, M. (1988).    Intrinsic laryngeal muscle activation in spasmodic dysphonia. In R.    Benecke, B. Conrad & C. D. Marsden (Eds.), Motor Disturbances (1    ed., pp. 119-130). Orlando: Academic Press.-   Ludlow, C. L., & Connor, N. P. (1987). Dynamic aspects of phonatory    control in spasmodic dysphonia. J Speech Hear Res, 30, 197-206.-   Ludlow, C. L., Hallett, M., Sedory, S. E., Fujita, M., &    Naunton, R. F. (1990). The pathophysiology of spasmodic dysphonia    and its modification by botulinum toxin. In A. Berardelli, R.    Benecke, M. Manfredi & C. D. Marsden (Eds.), Motor Disturbances (2    ed., pp. 274-288). Orlando: Academic Press.-   Ludlow, C. L., Humbert, I. J., Poletto, C. J., Saxon, K. S.,    Kearney, P. R., Crujido, L., et al. (2005). The Use of Coordination    Training for the Onset of Intramuscular Stimulation in Dysphagia,    Proceedings of the International Functional Electrical Stimulation    Society, 2005.-   Ludlow, C. L., Humbert, I. J., Saxon, K. G., Poletto, C. J.,    Sonies, B. C, & Crujido, L. (2006). Effects of surface stimulation    both at rest and during swallowing in chronic pharyngeal dysphagia.    Dysphagia, epub, May 23, 2006.-   Lundy, D. S., Smith, C, Colangelo, L., Sullivan, P. A., Logemann, J.    A., Lazarus, C. L., et al. (1999). Aspiration: cause and    implications. Otolaryngol Head Neck Surg, 120{4), 474-478.-   Mifflin, S. W. (1997). Intensity and frequency dependence of    laryngeal afferent inputs to respiratory hypoglossal motorneurons. J    Appl Physiol, 83, 1890-1899.-   Nishino, T., Tagaito, Y., & Isono, S. (1996). Cough and other    reflexes on irritation of airway mucosa in man. PuIm Pharmacol,    9(5-6), 285-292.-   Ootani, S., Umezaki, T., Shin, T., & Murata, Y. (1995). Convergence    of afferents from the SLN and GPN in cat medullary swallowing    neurons. Brain Res Bull, 37(4), 397-404.-   Park, C. L., O'Neill, P. A., & Martin, D. F. (1997). A pilot    exploratory study of oral electrical stimulation on swallow function    following stroke: an innovative technique. Dysphagia, 72(3),    161-166.-   Peurala S H, Pitkanen K, Sivenius J, Tarkka I M. Cutaneous    electrical stimulation may enhance sensorimotor recovery in chronic    stroke. Clin Rehabil. 2002; 16:709-716).-   Pick, N., McDonald, A., Bennett, N., Litsche, M., Dietsche, L.,    Legerwood, R., et al. (1996). Pulmonary aspiration in a long-term    care setting: clinical and laboratory observations and an analysis    of risk factors. J Am Geriatr Soc, 44(7), 763-768-   Pommerenke, W. T. (1927). A study of the sensory areas eliciting the    swallowing reflex. American Journal of Physiology, 84(1), 36-41.-   Portens C., Johns M N., Hapner E R (2008). A review of patient    adherence to the recommendations for voice therapy. J. Voice., 22:    1892-196.-   Power, M., Fraser, C, Hobson, A., Rothwell, J. C₁, Mistry, S.,    Nicholson, D. A., et al. (2004). Changes in pharyngeal corticobulbar    excitability and swallowing behavior after oral stimulation. Am J    Physiol Gastrointest Liver Physiol, 286(1), G45-50.-   Power, M. L., Fraser, C. H., Hobson, A., Singh, S., Tyrrell, P.,    Nicholson, D. A., et al. (2006). Evaluating oral stimulation as a    treatment for Dysphagia after stroke. Dysphagia, 21(λ), 49-55.-   Robbins, J., Butler S D G, Daniels, S K, Dierz Gross R, Langmore S.,    Lazarus C L, Martin-Harris B, McCabe D, Musson, Rosenbex, J. (2008)    Swallowing and dysphagia rehabilitation: translating principles of    neural plasticity into clinically orientated evidence. J Speech    Lang. Hear. Res., 51, S276-300.-   Rosenbek, J. C, Robbins, J. A., Roecker, E. B., Coyle, J. L., &    Wood, J. L. (1996). A penetration-aspiration scale. Dysphagia,    11(2), 93-98.-   Sedory-Holzer, S. E., & Ludlow, C. L. (1996). The swallowing side    effects of botulinum toxin type A injection in spasmodic dysphonia.    Laryngoscope, 106, 86-92.-   Setzen, M., Cohen, M. A., Perlman, P. W., Belafsky, P. C, Guss, J.,    Mattucci, K. F., et al. (2003). The association between    laryngopharyngeal sensory deficits, pharyngeal motor function, and    the prevalence of aspiration with thin liquids. Otolaryngol Head    Neck Surg, 128(1), 99-102.-   Sobotta, J. (1990). Sobotta Atlas of Human Anatomy (A. N. Taylor,    Trans. 11th English Edition ed. Vol. Volume 1 Head, Neck, Upper    limbs, skin). Baltimore-Munich: Urban & Schwarzenberg.-   Struppler A, Angerer B, Havel P. Modulation of sensorimotor    performances and cognition abilities induced by RPMS: clinical and    experimental investigations. Suppl Clin Neurophysiol. 2003;    56:358-367;-   Theurer, J. A., Bihari, F., Barr, A. M., & Martin, R. E. (2005).    Oropharyngeal stimulation with air-pulse trains increases swallowing    frequency in healthy adults. Dysphagia, 20(4), 254-260.-   van Dijk K R, Scherder E J, Scheltens P, Sergeant J A. Effects of    transcutaneous electrical nerve stimulation (TENS) on non-pain    related cognitive and behavioural functioning. Rev Neurosci. 2002;    13:257-270;-   Wijting, Y., & Freed, M. L. (2003). VitalStim Therapy Training    Manual. Hixson, Tenn.: Chattanooga Group.

While specific embodiments of the subject invention have been discussed,the above specification is illustrative and not restrictive. Manyvariations of the invention will become apparent to those skilled in theart upon review of this specification. The full scope of the inventionshould be determined by reference to the claims, along with their fullscope of equivalents, and the specification, along with such variations.

Unless otherwise indicated, all numbers expressing quantities ofingredients, reaction conditions, and so forth used in the specificationand claims are to be understood as being modified in all instances bythe term “about.” Accordingly, unless indicated to the contrary, thenumerical parameters set forth in this specification and attached claimsare approximations that may vary depending upon the desired propertiessought to be obtained by the present invention.

What is claimed is:
 1. A device comprising: a stimulator configured toapply at least one stimulus to the outside surface of a neck of asubject; a switch configured to selectively engage between a manual modein which the stimulator is configured to apply the at least one stimulusupon volitional activation by the subject, and an automatic mode inwhich the stimulator is configured to apply the at least one stimulus atan interval; and a first counter configured to determine either a numberof applications of the at least one stimulus in the manual mode, or anumber of applications of the at least one stimulus in the automaticmode.
 2. The device of claim 1, further comprising a second counterconfigured to determine either the number of applications of the atleast one stimulus in the manual mode, or the number of applications ofthe at least one stimulus in the automatic mode, the configuration ofthe second counter opposite the configuration of the first counter. 3.The device of claim 1, wherein the at least one stimulus comprises avibrational stimulus, a pressure stimulus, an auditory stimulus, atemperature stimulus, a visual stimulus, an olfactory stimulus, agustatory stimulus, or a combination thereof.
 4. The device of claim 1,wherein the at least one stimulus comprises vibratory stimulus.
 5. Thedevice of claim 4, wherein the vibrating stimulus is at a vibrationalfrequency between about 1 Hz and about 100 Hz.
 6. The device of claim 4,wherein the vibrating stimulus is at a vibrational frequency betweenabout 5 Hz and about 70 Hz.
 7. The device of claim 4, wherein thevibrating stimulus is at a vibrational frequency between about 30 Hz andabout 60 Hz.
 8. The device of claim 4, wherein the at least one stimuluscomprises pressure stimulus applied to the outside surface of the neckof the subject.
 9. The device of claim 9, wherein the stimulator isconfigured to apply pressure of about 1 psi to about 14 psi to the neckof the subject.
 10. The device of claim 1, wherein a duration of the atleast one stimulus is between about 2 seconds and about 6 seconds. 11.The device of claim 1, wherein the interval is between about 3 minutesand about 30 minutes.
 12. The device of claim 1, wherein the at leastone stimulus is configured to induce a swallowing reflex of the subject.13. The device of claim 1, wherein the at least one stimulus isconfigured to initiate speech of the subject.
 14. The device of claim 1,further comprising a physiological sensor.
 15. The device of claim 14,wherein the physiological sensor is selected from the group consistingof movement sensors, temperature sensors, skin color sensors, hematocritsensors, oxygenation sensors, and blood pressure sensors.
 16. A methodfor monitoring subject compliance with a training or therapy regime, themethod comprising analyzing data from the device of claim 1 after aperiod of use of the device by the subject:
 17. The method of claim 16,further comprising manually interrogating the first counter.
 18. Themethod of claim 16, further comprising manually resetting the firstcounter.
 19. The method of claim 16, further comprising remotelyinterrogating the first counter.
 20. The method of claim 16, furthercomprising remotely resetting the first counter.